Anomalous aortic origin of coronary arteries: an alternative to the unroofing strategy.
Gaillard M, Pontailler M, Danial P, Moreau de Bellaing A, Gaudin R, du Puy-Montbrun L, Murtuza B, Haydar A, Malekzadeh-Milani S, Bonnet D, Vouhé P, Raisky O.Eur J Cardiothorac Surg. 2020 Nov 1;58(5):975-982. doi: 10.1093/ejcts/ezaa129.PMID: 32572445
Take Home Points:
- In anomalous aortic origin of the coronary artery (AAOCA) with an intramural and interarterial course, unobstructed blood flow to the coronary from the appropriate sinus is the desired goal.
- Although unroofing is the most frequent procedure, alternative surgical techniques may achieve the goal with particular advantages, especially when unroofing is not possible or desirable.
- Despite success in the surgical treatment of AAOCA with little or no mortality, coronary events and reintervention rates remain significant.
Commentary from Dr. Luis Quinonez (Boston, MA, USA), section editor of Congenital Heart Surgery Journal Watch: This paper describes the experience of Hopital Necker, Paris with the surgical treatment of anomalous origin of coronary artery (AAOCA) from an inappropriate sinus and an interarterial course. Sixty-one patients are included with a median age of 14.7 years (3.7-66.1). There were 40 anomalous right and 21 left coronaries; 5 anomalous left coronaries had an intraseptal course. 70% of the patients were symptomatic, most commonly chest pain. 5 patients had sudden death. Interestingly, of the 34 patient that were tested for inducible ischemia, 41.2% were positive. The surgical techniques describe include osteoplasty (37 patients, 60.7%), which is opening the coronary artery at its exit point in the appropriate sinus and carrying the incision proximally into the aorta and then adding a patch (mostly autologous pericardium; the other technique is coronary translocation (18 patients, 31.1%), where the coronary is transected at its exit point and relocated in the appropriate sinus augmenting the anastomosis with an autologous pericardial patch. The last technique described is one for the intraseptal course (5 patients, 8.2%) where the pulmonary root is harvested like a Ross, the muscle bridge is unroofed, and the autograft is re-implanted. There were no operative deaths. Complications are described. Follow-up was 38 months (1-15 years).
This series has a respectable number of patients in which surgical techniques are presented. The descriptions, illustrations and video are sufficient to understand and reproduce the techniques. Notably, the operations are not unroofings, which is the probably the “standard” approach to AAOCA from an inappropriate sinus. In the operations described, the intramural segment of the anomalous coronary is left untouched. This is important, given the concern that manipulation of the intercoronary commissure risks early or late aortic valve insufficiency. This complication has been brought to the forefront by the recently published Congenital Heart Surgeons Society multicenter report and will likely garner interest in techniques that will avoid the commissure. For the osteoplasty technique, there are now two sources of blood flow to the coronary, the intramural course and the osteoplasty site. Does this put at risk the osteoplasty site (competitive flow) or is the intramural course at risk of thrombosis? Although there were no operative deaths, there were 3 acute post-operative coronary events, all requiring re-intervention and 1 needing ECMO. This is 3 of 61 patients, or 5%, which is not a small number. In the follow-up period there were no reported deaths, yet another 3 patients had re-interventions. Although they report all patients, but one, were asymptomatic, their follow-up testing was incomplete, with only about half the patients having inducible ischemia testing and about 60% having CT imaging, making the ability to draw conclusions limited. A very good part of the paper is the discussion, in which the authors describe the technical lessons learned from their experience. Overall, this paper is worth reading for anyone tackling AAOCA. Although the operations described may be more technically demanding, they are options if unroofing is not possible or desirable.