Anomalous aortic origin of coronary arteries: an alternative to the unroofing strategy

Abstract

OBJECTIVES Anomalous aortic origin of a coronary artery (AAOCA) is the second leading cause of sudden death in children and young adults. The most threatening anatomy is an interarterial and an intramural course, both probably involved in ischaemic phenomena and sudden death. The treatment of interarterial AAOCA remains controversial. Most of the published studies describe the results of the unroofing technique. Our study aims to evaluate the results of a different surgical approach. METHODS From 2005 to 2019, 61 patients were operated on for an interarterial AAOCA (median age 14.7 years). Forty patients had a right AAOCA, and 21 patients had a left AAOCA including 5 patients with intraseptal course. Seventy percent of patients were symptomatic. Five patients had an aborted sudden cardiac death. Two surgical techniques were used: an ‘anatomical’ repair for 35 patients (15 left and 22 right AAOCA) or a coronary translocation with creation of a neo-ostia in 19 patients (1 left and 18 right AAOCA). The 5 left AAOCA patients with an intra-septal course required a complete release of the coronary artery from the septum. RESULTS There was no early or late postoperative death. Three patients had an acute postoperative ischaemic event. Two patients required immediate angioplasty and stenting: 1 patient (7 years) with a hypoplastic right AAOCA and 1 patient (66 years) for inadequate tailoring after septal release. The third patient required an immediate surgical revision (H-2) for left AAOCA thrombosis at the level of the pericardial patch with full myocardial recovery at discharge. During follow-up, 1 patient with right AAOCA translocation and chronic chest pain required subsequent stenting and finally a coronary artery bypass grafting 2 years after initial surgery. One patient who had an asymptomatic mild right coronary stenosis 1 year after anatomical repair was successfully treated by angioplasty alone. All patients but 1 who underwent coronary translocation are totally asymptomatic. All patients with anatomical repair or septal release are free from ischaemic symptoms. CONCLUSIONS Anatomical repair might provide a better protective option for these patients. Unlike unroofing, it treats the entire intramural segment, relocates the ostium at the appropriate sinus level and corrects any acute take-off angle.

Surgery for Anomalous Aortic Origin of Coronary Arteries: Technical Safeguards and Pitfalls

“…An alternative technique for AAOCA with ostial stenosis and the intramural course is extensive coronary ostioplasty, also called "anatomical surgical repair." As reported by Vouhè et al (27,31),…”

“…An alternative technique for AAOCA with ostial stenosis and the intramural course is extensive coronary ostioplasty, also called “anatomical surgical repair.” As reported by Vouhè et al ( 27 , 31 ), the anomalous coronary ostium is completely reconstructed by two incisions, one in the aortic sinus and the other longitudinally on the initial epicardial course of the anomalous coronary artery, which are then joined together.…”

“…Doing this, the commissure is left intact, and the risk of iatrogenic aortic insufficiency (due to commissure takedown) may be minimized. According to Vouhè et al ( 27 , 31 ), this technique may be effective in most anatomical variants with or without an intramural course, except those with an acute take-off angle or commissural ostial location. The reported early and mid-term results are satisfactory, although the long-term outcomes are still unknown.…”

“…The reported early and mid-term results are satisfactory, although the long-term outcomes are still unknown. However, it is a more technically demanding procedure, with a patch in the coronary course, which may thrombose in the long term ( 27 ).…”

“…One question that remains is which patch material is best. Vouhè et al ( 27 ) suggest a pericardial patch, preferably. However, long-term results are needed to verify what is best.…”