Patch Augmentation of Anomalous Left Main Coronary Artery from Right Coronary Sinus

The Patient

The patient is a fifty-three-year-old male with medical history notable for neuroendocrine tumor, which was treated with a pylorus-preserving pancreaticoduodenectomy. The patient was symptomatic and complained of shortness of breath. The preoperative study started with a transthoracic echocardiogram, which showed severe (4+) aortic valve regurgitation due to prolapse with an anteriorly directed regurgitant jet and a peak gradient of 20 mmHg. The left ventricle was dilated and the ejection fraction was normal.

Coronary catheterization (CTA) showed the left and right coronary arteries where the left main originates from the right sinus and undergoes an interarterial course between the ascending aorta and the pulmonary artery before trifurcating into the left anterior descending (LAD), ramus, and circumflex branch of the left coronary artery. There was no obvious intramural course.

On invasive hemodynamic assessment with instantaneous wave-free ratio during stress with dobutamine, there was evidence of significant flow limitation in the LAD during stress (0.75 vs 0.95 at rest), accompanied by frequent ventricular ectopy.

Consequently, the surgical plan was a saphenous patch augmentation of the anomalous left main coronary artery from the right coronary sinus, plus a tissue aortic valve replacement.

The Surgery

After aortic clamping and induction of cardioplegic arrest, the normal epicardial course of the left coronary artery was identified by removing the surrounding connective tissue. Next, the ascending aorta was divided above the sinotubular junction to both visualize the coronary ostium and gain better exposure of the epicardial course of the anomalous coronary artery.

The left main coronary artery was then opened longitudinally. The incision began distally and carried out upstream towards the aortic wall. A vertical incision was then made in the right sinus from the cut edge of the aorta to reach the coronary arteriotomy. Both incisions were then joined together.

Next, the grater saphenous vein was used as a patch and implanted to create a new large left coronary ostium. There was a small abnormal intramural segment, which was left intact. The anastomosis was then performed, incorporating the top edge of the patch to the left main coronary artery, and sewn upstream towards the aortic wall.

Surgeons then began the aortic valve replacement with a valve leaflets excision. After the annulus was debrided of calcium deposits, pledgeted, noneverting mattress sutures were used for valve implantation.

First, the vein was divided, leaving a rim. This free edge was then folded once by sewing each corner to the aortic wall. The aortic anastomosis was completed, incorporating the free edge of the patch into the anastomotic suture line.

The postoperative coronary CTA showed a patch augmentation with a saphenous graft of the anomalous left main trunk originating from the right coronary sinus.

References

1. Gaudin R, Raisky O, Vouhé PR: Anomalous aortic origin of coronary arteries: “anatomical “surgical repair. Multimed Man Cardiothorac Surg 2014;2014:mmt022.
2. Mainwaring RD, Reddy VM, Reinhartz O,et al: Surgical repair of anomalous aortic origin of a coronary artery. Eur J Cardiothorac Surg 2014;46:20-26.

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