Invited Commentary

Abstract

The optimal treatment for anomalous aortic origin of a coronary artery (AAOCA) is controversial. At the crux of the controversy lies an incomplete understanding of the pathophysiology of sudden cardiac death in these patients, the actual risk conferred by different anatomies, and the uncertain effects of surgical intervention on reducing that risk. Multiple different techniques have been used in an attempt to rectify the anatomy and reduce the risk in AAOCA. Law and colleagues [1Law T. Dunne B. Stamp N. Ho K.M. Andrews D. Surgical results and outcomes after reimplantation for the management of anomalous aortic origin of the right coronary artery.Ann Thorac Surg. 2016; 102: 192-199Google Scholar] present a series of 16 patients that underwent coronary translocation. Based on their midterm outcomes, they suggest that coronary translocation should be the treatment of choice for surgical management of AAOCA. Other series have advocated surgical unroofing as the best treatment for these patients [2Sharma V. Burkhart H.M. Dearani J.A. et al.Surgical unroofing of anomalous aortic origin of a coronary artery: a single-center experience.Ann Thorac Surg. 2014; 98: 941-946Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar], a technique that accounts for almost 90% of cases on AAOCA patients <30 years of age in the United States [3Poynter J.A. Bondarenko I. Austin E.H. et al.Repair of anomalous aortic origin of a coronary artery in 113 patients: a Congenital Heart Surgeons’ Society report.World J Pediatr Congenit Heart Surg. 2014; 5: 507-514Crossref PubMed Scopus (45) Google Scholar]. Coronary translocation is an attractive technique because it not only addresses the intramural segment (if the coronary is divided at its exit point rather than harvested as a button) but also places the ostium in its correct sinus, therefore addressing the interarterial segment that some consider important in the pathophysiology. On the other hand, it implies manipulating the coronary itself and creating a circumferential anastomosis, with its unknown long-term consequences. This is a major consideration since a large proportion of patients with AAOCA are children and adolescents with an expected life expectancy that should be measured in decades, rather than years. This series, just as all other AAOCA series, suffers from a relatively short follow-up (mean follow-up of 5 years). It may also be naïve to think that a one-size-fits-all strategy will ultimately be the optimal approach for AAOCA. It is possible (and likely) that different techniques may be best for different patients with different specific morphologies. Coronary translocation may be useful in patients with a short intramural segment in which surgical unroofing fails to move the ostium to the correct sinus or those with a thick intercoronary column that could still impinge on the coronary ostium after unroofing. On the other hand, surgical unroofing may well be the optimal technique on younger patients with a long intramural segment. Only one thing is clear: we need more data. Only by aggregating experience from different centers and compulsively following patients for a long time will we achieve our ultimate goal of understanding AAOCA and provide the right treatment for the right patient at the right time. Surgical Results and Outcomes After Reimplantation for the Management of Anomalous Aortic Origin of the Right Coronary ArteryThe Annals of Thoracic SurgeryVol. 102Issue 1PreviewAnomalous aortic origin of the right coronary artery (AAORCA) has been reported to cause myocardial ischemia, leading to angina, dyspnea, and decreased exercise tolerance. Reimplantation is a repair technique devised to exclude the abnormal intramural portion of the anomalous artery and avoid the known late attrition of saphenous vein grafts. Our study aims to evaluate the medium-term clinical outcomes with this technique. Full-Text PDF