Anomalous Aortic Origin of the Right Coronary Artery From the Wrong Sinus of Valsalva (AAORCA): Two Surgical Strategies

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.  

Anomalous aortic origin of the right coronary artery (AAORCA) is frequently diagnosed, and decision-making regarding surgical intervention remains controversial in asymptomatic patients. Two cases of AAORCA in two symptomatic patients are presented, each treated with different surgical techniques due to variations in their anatomy. 

First Patient

The first patient was a 15-year-old who presented with chest pain and had a positive exercise test. Preoperative CTA showed AAORCA with an intramural course. A decision was made to proceed with surgical unroofing. The procedure was performed though median sternotomy and normothermic cardiopulmonary bypass (CPB) with aortic and single venous cannulation. An oblique aortotomy was performed in a hockey-stick fashion, and the intramural segment was identified and unroofed. The edges of the unroofed segment were trimmed, and multiple interrupted 7-0 polypropylene sutures were used to keep the edges everted. The right coronary artery (RCA) ostium was transferred from the left sinus of Valsalva to the right sinus, where it normal originates. The aortotomy was then closed in two layers, the heart was deaired, and the aortic cross-clamp was removed. The patient was weaned off CPB in the standard fashion. Post-bypass transesophageal echocardiogram (TEE) showed good flow in the RCA and good biventricular functions. The rest of the procedure was completed in the standard fashion, and the patient was extubated in the operating room. The aortic cross-clamp time and CPB time were 50 and 62 minutes. respectively. The postoperative course was uneventful, and the patient was discharged three days later. 

Second Patient

The second patient was a morbidly obese 37-year-old man who presented with chest pain and a positive stress test. CTA showed a high takeoff of the RCA with an interarterial course between the aorta and the main pulmonary artery, with no intramural course. Due to symptoms and the positive stress test, a decision was made to proceed with repair via translocation of the anomalous RCA. 

The procedure was performed in a similar manner to the first case. Through a median sternotomy and normothermic cardiopulmonary bypass, antegrade cardioplegic arrest was achieved, and an oblique high aortotomy was performed. The anomalous RCA ostium was identified and harvested with a large button from the aorta. The RCA’s native location was reconstructed with an appropriately sized bovine pericardial patch. The RCA was then translocated to a new, higher location on the ascending aorta anteriorly. The aortotomy was closed in a two-layer fashion. The heart was then deaired, and the aortic cross-clamp was removed. The patient was ventilated and weaned off CPB without difficulty. Intraoperative fluorescent angiography with indocyanine green was performed, along with ultrasound flow assessment of the RCA. All confirmed good flow in the RCA. The rest of the procedure was completed in the standard fashion. 

The aortic cross-clamp and CPB times were 43 and 70 minutes, respectively. Predischarge CTA showed a widely patent RCA ostium in its new location. The patient was discharged seven days later. 

Both patients reported improvement in their symptoms during the follow-up period. 

References

1. Said SM, Dearani JA, Burkhart HM, Schaff HV. Surgical management of congenital coronary arterial anomalies in adults. Cardiol Young. 2010 Dec;20 Suppl 3:68-85
2. Said SM. Coronary Artery Bypass for Anomalous Coronary Arteries: Something I Will Not Do. Ann Thorac Surg. 2021 Jan;111(1):377

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