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

Abstract

Anomalous aortic origin of a coronary artery (AAOCA) is reported as the second leading cause of sudden cardiac death in otherwise healthy young individuals. Several surgical studies have reported a shallow operative risk, describing repair as safe and effective with short or medium-term follow-up. However, surgical repair can also be associated with a high risk of complications. Numerous repair techniques have been described in the literature, but each technique's indications and limitations are often not well-understood or understated. Since explicit technical knowledge of the most appropriate surgical technique is highly desirable, we sought to thoroughly and clearly outline the safeguards and pitfalls of the most common surgical techniques used to repair AAOCA.

Prevalence, characteristics and management of anomalous coronary arteries in individuals undergoing cardiac computed tomography

“…Guidelines recommend surgery for left coronary artery anomalies with malignant course or in symptomatic individuals, yet the role of surgery for asymptomatic RCA anomalies remains controversial [3,4]. Notably, anomalous RCA was the most common in this study, yet the majority did not undergo surgery despite demonstrating a malignant course or ‘slit-like’ ostium (another high-risk anatomical feature), indicating that many clinicians favour conservative management and close observation initially [5].…”

“…It is thought that an interarterial course (between the aorta and pulmonary artery) or intramural course (within the aortic wall) carries a greater risk of SCD, however, this is based predominantly on autopsy studies [2]. Furthermore, the optimal approach to risk-stratification and management of AOCA is controversial, as recommendations for surgery are based on limited observational data with short follow-up and concerns regarding the risk of surgical complications in asymptomatic individuals [3,4].…”

Therapeutic Management of Anomalous Coronary Arteries Originating From the Opposite Sinus of Valsalva: Current Evidence, Proposed Approach, and the Unknowing

“… 52 , 75 , 76 An overview of the most relevant clinical trials with regard to treatment of patients with ACAOS is depicted in Table 2 . 28 , 37 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 Although coronary “unroofing” is the most common surgical procedure reported in the literature, 76 currently there are no recognized guideline recommendations on surgical techniques (neither in the American Heart Association/American College of Cardiology 2018 guidelines 19 nor in the European Society of Cardiology 2020 guidelines 20 ). Various surgical techniques have been reported, and the most common procedures with their advantages and limitations are outlined below.…”

A comprehensive analysis of the intramural segment in interarterial anomalous coronary arteries using computed tomography angiography

“…With this technique, the intramural part of the coronary artery is resected. 1 , 2 , 6 , 9 Since the identification of an intramural segment has important consequences for the evaluation of the surgical indication and technique, reliable diagnostic criteria are required for robust identification and characterization of the intramural segment of the ACAOS. 8 , 9 To date, assessment of the presence of an intramural segment is done by using, separately or combined, the degree of proximal narrowing, the coronary artery lumen shape, and the presence of a slit-like orifice, acute angle take-off, or peri-coronary fat.…”

“… 1 , 2 , 6 , 9 Since the identification of an intramural segment has important consequences for the evaluation of the surgical indication and technique, reliable diagnostic criteria are required for robust identification and characterization of the intramural segment of the ACAOS. 8 , 9 To date, assessment of the presence of an intramural segment is done by using, separately or combined, the degree of proximal narrowing, the coronary artery lumen shape, and the presence of a slit-like orifice, acute angle take-off, or peri-coronary fat. 6 , 10–16 Methods to adequately diagnose an intramural course on CTA may omit the necessity for invasive haemodynamic evaluation and improve the identification of patients who would benefit from surgical intervention.…”