Coronary Artery Bypass for Anomalous Coronary Arteries: Something I Will Not Do

Abstract

I read with interest the article by Gaudino and colleagues 1 Gaudino M. Robinson N.B. Hameed I. Girardi L.N. Coronary bypass with the free internal thoracic artery to treat anomalous right coronary artery. Ann Thorac Surg. 2020; 109: e371-e373 Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar regarding the use of the free right internal mammary artery (RIMA) to treat anomalous right coronary artery (RCA) in 3 young adult patients. I congratulate the authors on the successful results. However, I have the following concerns and queries: (1) the authors’ comment about surgical treatment of anomalous coronary arteries being controversial is inaccurate. Although controversy may exist in asymptomatic patients with anomalous RCA origin, 2 Brothers J.A. Frommelt M.A. Jaquiss R.D.B. Myerburg R.J. Fraser Jr., C.D. Tweddell J.S. Expert consensus guidelines: anomalous aortic origin of a coronary artery. J Thorac Cardiovasc Surg. 2017; 153: 1440-1457 Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar the indications for symptomatic patients are clear and the technique of unroofing is more or less standard, assuming we are talking about the intramural variant. 3 Said S.M. Dearani J.A. Burkhart H.M. Schaff H.V. Surgical management of congenital coronary arterial anomalies in adults. Cardiol Young. 2010; 20: 68-85 Crossref PubMed Scopus (9) Google Scholar (2) The authors did not describe the nature of the anomalous origin of the RCA and whether it was intramural or had high-risk features on computed tomography scan. (3) The treatment described is not new, and although it is successful, some may still consider it more aggressive compared with a simple unroofing of an intramural segment of the coronary artery. (4) The authors justified their choice for free versus in situ RIMA for the current series; however, compared with standard coronary bypass in the presence of proximal native coronary artery disease, we do not know the long-term outcomes of the current strategy, especially in young patients with long life expectancy. (5) Although I do not completely eliminate the role of coronary artery bypass grafting in anomalous coronary arteries, patient selection is critical, and I personally consider this strategy only in older patients with concomitant coronary artery disease. Coronary Bypass With the Free Internal Thoracic Artery to Treat Anomalous Right Coronary ArteryThe Annals of Thoracic SurgeryVol. 109Issue 5PreviewThe surgical treatment of anomalous origin of the coronary artery remains controversial. We present 3 cases of young adults who underwent free right internal thoracic artery to right coronary artery bypass for the treatment of symptomatic anomalous origin of the right coronary artery. Full-Text PDF Why Surgical Treatment of Anomalous Coronary Arteries Is Still Up for Debate: ReplyThe Annals of Thoracic SurgeryVol. 111Issue 1PreviewWe thank Dr Said1 for his insightful comments and critiques. Although he raises important points regarding the optimal corrective strategy for anomalous origin of the coronary artery (AOCA), several considerations must be made. First, his letter is evidence per se that there is certainly continued debate regarding the most effective treatment strategy for AOCA. Second, although we agree that coronary unroofing remains the surgical treatment of choice in the pediatric population, in adults unroofing can be technically challenging and unpredictable, requiring aortic valve resuspension in up to 12% of patients. Full-Text PDF