Direct Coronary Reimplantation for Repair of Anomalous Aortic Origin of Left or Right Coronary Artery

Abstract

We read with great interest the article by Romp and colleagues [1Romp R.L. Herlong J.R. Landolfo C.K. et al.Outcome of unroofing procedure for repair of anomalous aortic origin of left or right coronary artery.Ann Thorac Surg. 2003; 76: 589-596Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar] on an unroofing technique for repair of anomalous aortic origin of the left or right coronary artery. Nine consecutive patients underwent unroofing procedures for the repair of anomalous aortic origin of a coronary artery from the incorrect sinus of Valsalva. The technique was carried out with minimal risk and good anatomic and functional results. In this series, 1 of the patients subsequently underwent aortic valve replacement because of the development of severe aortic insufficiency. At the time of reoperation, the pathological finding noted was prolapse of the intercoronary commissure. The authors adopted two unroofing procedures, one with and the other without extensive unroofing of the intramural segment. In the patient who later had aortic valve replacement, the unroofing procedure involved takedown and reattachment of the intercoronary commissure. The major unroofing procedure with and without disruption of the commissure used in 7 patients may well weaken the support of the commissure. Therefore, aortic regurgitation might develop in the other 6 patients in the future. In addition, there are several questions concerning the technique. The location of the neo-ostium must be determined individually because of anatomic variation in the intramural segment of the coronary artery. If the segment is short, the neo-ostium is made near the commissure. Is it difficult to create a neo-ostium under these circumstances? It appears to be very close to the commissure in Figure 4 [1Romp R.L. Herlong J.R. Landolfo C.K. et al.Outcome of unroofing procedure for repair of anomalous aortic origin of left or right coronary artery.Ann Thorac Surg. 2003; 76: 589-596Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar]. Creating a new orifice without major unroofing and disruption of the commissure would be better than creating one with this technique. However, can the technique be performed in all cases of anomaly? Its applicability depend on the anatomy in each instance. Recently, we [2Furukawa K. Sakaguchi M. Ohtsubo S. Itoh T. Direct coronary reimplantation for anomalous origin of the right coronary from the left sinus of Valsalva.Interactive Cardiovasc Thorac Surg. 2002; 2: 190-192Crossref Scopus (11) Google Scholar] had a patient with anomalous origin of the right coronary artery from the left sinus of Valsalva. We performed direct coronary reimplantation and obtained a good result. The patient is doing well 17 months postoperatively. Reimplantation is difficult because the anomalous artery cannot be excised with a Carrel patch, as its course can be within the aorta initially, and the ostium is often slitlike [3Shah A.S. Milano C.A. Lucke J.P. Anomalous origin of the right coronary artery from the left coronary sinus case report and review of surgical treatments.Cardiovasc Surg. 2000; 8: 284-286Crossref PubMed Scopus (26) Google Scholar]. Therefore, few reports of such a method are available [4Di Lello F.D. Mnuk J.F. Flemna R.J. Mullen D.C. Successful coronary reimplantation for anomalous origin of the right coronary artery from the left sinus of Valsalva.J Thorac Cardiovasc Surg. 1991; 102: 455-456PubMed Google Scholar, 5Fernandes E.D. Kadivar H. Hallman G.L. Reul G.J. Ott D.A. Cooley D.A. Congenital malformations of the coronary arteries the Texas Heart Institute experience.Ann Thorac Surg. 1992; 54: 732-740Abstract Full Text PDF PubMed Scopus (264) Google Scholar]. In the technique for an anomalous right coronary artery, the segment of the right coronary artery apposing the anterior wall of the aorta should be divided and reanastomosed. However, there is a risk of stretching the artery. Possibly, the divided artery could be reanastomosed, without tension, using extensive dissection and mobilization of the right coronary artery [2Furukawa K. Sakaguchi M. Ohtsubo S. Itoh T. Direct coronary reimplantation for anomalous origin of the right coronary from the left sinus of Valsalva.Interactive Cardiovasc Thorac Surg. 2002; 2: 190-192Crossref Scopus (11) Google Scholar]. Also, with the reimplantation technique, the divided artery should be tailored proximally in the shape of a cobra head to avoid ostial stenosis. The reimplantation technique might be problematic for a left coronary artery arising from the right sinus of Valsalva because of difficulties associated with extensive dissection and mobilization of the left main coronary artery, the proximal left anterior descending coronary artery, and the left circumflex coronary artery. However, we believe the reimplantation technique is a true anatomic correction for a right coronary artery arising from the left sinus of Valsalva. Excellent longevity of the directly reimplanted coronary artery can be expected.