Minimally Invasive Treatment of Anomalous Aortic Origin of the Right Coronary Artery

This article is part of CTSNet’s Guest Editor Series, Coronary Arterial Anomalies—Pediatric and Adult Congenital. CTSNet Senior Editor Dr. Sameh Said invited both pediatric and adult cardiac surgeons from around the world to contribute clinical videos on various coronary arterial anomalies and different surgical techniques that are used to manage them.    

Coronary arteries supplying the heart typically originate from their respective sinuses. An abnormal origin of these arteries is a congenital condition in which they do not follow the normal pattern from the left or the right sinuses. This anomaly is often diagnosed as an incidental finding during CT scans or angiography. 

The abnormal origin of coronary arteries is a very rare pathology, with an incidence rate of less than 1% and a prevalence of about 2.33 percent (1). Coronary artery anomalies can arise from a pulmonary artery or from the contralateral or incorrect aortic sinus. Angelini classified coronary artery anomalies into four categories (2):  

1. Anomalies of origin and course of coronary arteries  
2. Anomalies of intrinsic coronary anatomy 
3. Anomalies of coronary artery termination  
4. Anomalous collateral vessels  

The most common type of origin observed is ectopic aortic origin, with an anomalous origin from the wrong sinus of Valsalva predominating (3). This latter congenital condition can lead to sudden death or myocardial infarction in adults (4). In this case, the implicated mechanism is dynamic compression during exertion of the coronary artery between the aorta and the pulmonary trunk.  
The surgical treatment for these patients is usually performed via sternotomy and may involve reimplantation of the coronary artery to the adequate sinus or unroofing of the initial aortic path of the artery (5). 

This video presents a technique used in a patient with chest pain and an anomalous origin of the right artery. The surgeons approached the reimplantation through an anterior right minithoracotomy, a method routinely performed for aortic valve replacement, which has become the authors’ gold-standard approach. Surgical exposure was excellent during the surgery, and reimplantation of the right coronary artery at the level of the right sinus was completed without any difficulty. The patient did well in the postoperative period and was discharged home on day six. He resumed his normal life, and after six months of follow-up, he was able to participate in sports without experiencing any chest pains.  

Minimally invasive surgery could be safely applied to many pathologies, including congenital ones, improving rehabilitation and allowing a rapid return to active life in young patients. 

References

1. Toshniwal SS, Toshniwal SS, Kumar S, Acharya S. Aberrant Right Coronary Artery from the Left Coronary Sinus Presenting with Inferior Wall Myocardial Infarction. Int J Appl Basic Med Res 2024;14:199201.
2. Angelini P. Coronary artery anomalies: an entity in search of an identity. Circulation 2007;115:1296305.
3. Angelini P. What is in a name? The need for strict diagnostic criteria in computerized tomographic angiography of anomalous coronary artery originating from the opposite aortic sinus. Am J Cardiol 2013;111:1680.
4. Angelini P, Uribe C. Symptomatic right coronary anomaly with dynamic systolic intramural obliteration and isolated right ventricular ischemia. Catheter Cardiovasc 2019;93:4457.
5. Sainathan S, Mullinari L, Arumugam N. Ostial Atresia After Coronary Unroofing for Anomalous Aortic Origin of the Left Coronary Artery. World J Pediatr Congenit Heart Surg 2024;21501351241269857.

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