Anomalous aortic origin of coronary arteries: is the unroofing procedure always appropriate?

Anomalous aortic origin of coronary arteries: is the unroofing procedure always appropriate?

Mostefa Kara M, Fournier E, Cohen S, Hascoet S, Van Aerschot I, Roussin R, El Zoghbi J, Belli E.Eur J Cardiothorac Surg. 2020 Nov 9:ezaa379. doi: 10.1093/ejcts/ezaa379. Online ahead of print.PMID: 33167026


Teaching Points

  • Unroofing is a safe and effective technique for the majority of AAOCA.
  • Surgical correction of AAOCA should be offered to symptomatic patients and high-risk asymptomatic patients.
  • Intramural course is underestimated on CT and should always be rule out intraoperatively.

Dr. Charles Laurin


Commentary from Dr. Charles Laurin (Quebec City, QC, Canada), guest editor of Congenital Heart Surgery Journal Watch: Kara et al, from Marie Lannelongue Hospital, published in the European Journal of Cardio-Thoracic Surgery in November 2020 their last fifteen years experience with anomalous aortic origin of coronary arteries (AAOCA). The retrospective analysis of 39 consecutive cases (median age at surgery of 14 years) aim to define the optimal surgical technique for the majority of AAOCA and to discuss the justification of surgery for all AAOCA, with or without symptoms.


The cohort included 11 anomalous left coronary artery (ALCA) and 28 anomalous right coronary arteries (ARCA), from which respectively 10 (90%) and 21 (75%) were symptomatic. The two patients operated after sudden death episode had ARCA. Preoperative cardiothoracic scans (CT) showed 19 (49%) intramural course (5 ALCA; 15ARCA) and 27 (69%) interarterial course (8 ALCA;19 ARCA). Intraoperative intramural course was noted in 28 patients (8 ALCA;20 ARCA). Unroofing technique was successful in 30 (77%) patients with 11 needing adjunct pulmonary translocation and 3 resuspensions of the inter-coronary commissure. Survival rate was 100% at median time of 4 years (3-6). Three patients needed reoperations for recurrence of symptoms, which all had thrombosed bypass grafts.


With 64% of the cohort operated in the last five years, management guidelines of AAOCA have become more aggressive, especially regarding asymptomatic AAOCA. Surgical treatment has been extended to high-risk anatomy and asymptomatic patient (small lumen area, high degree of proximal stenosis, long interarterial course, small proximal segment width). ARCA was more prevalent and seemed at higher risk of sudden death event. The majority of symptomatic patients had intramural course. Nevertheless, 11 patients had no intramural course, and all were symptomatic. As reported by the authors, AAOCA intramural course was underestimated by preoperative imaging (49% vs 72% intraoperatively), which should warrant intraoperative systematic evaluation for undiagnosed intramural course. Coronary unroofing is a safe technique to address AAOCA with favourable midterm outcomes. Depending on anatomy, alternative techniques can be performed on top of unroofing. Bypass grafts should be avoided because of highly competitive flow with the native coronary artery, which lead to bypass occlusion.