Surgical Unroofing for Anomalous Aortic Origin of Coronary Arteries

Abstract

Anomalous aortic origin of a coronary artery (AAOCA) from an opposite sinus of Valsalva is an uncommon congenital defect that is typically only discovered on cardiac catheterization or on autopsy following sudden cardiac death. Conjectured mechanisms for the ischemia are generally believed to relate to the unique and easily obstructed geometry of the coronary ostium and the stenotic intramural coronary segment. Given the potentially devastating consequences of not repairing an AAOCA—that is, sudden cardiac death—these patients should undergo repair of the anomaly when it is discovered. Multiple options for surgically correcting the AAOCA have been developed, and the most used approaches include coronary artery bypass grafting, coronary reimplantation, and unroofing of the intramural segment. Here we present the technique for surgical unroofing of the intramural segment of an anomalous coronary artery of aortic origin. Anomalous aortic origin of a coronary artery (AAOCA) from an opposite sinus of Valsalva is an uncommon congenital defect that is typically only discovered on cardiac catheterization or on autopsy following sudden cardiac death. Conjectured mechanisms for the ischemia are generally believed to relate to the unique and easily obstructed geometry of the coronary ostium and the stenotic intramural coronary segment. Given the potentially devastating consequences of not repairing an AAOCA—that is, sudden cardiac death—these patients should undergo repair of the anomaly when it is discovered. Multiple options for surgically correcting the AAOCA have been developed, and the most used approaches include coronary artery bypass grafting, coronary reimplantation, and unroofing of the intramural segment. Here we present the technique for surgical unroofing of the intramural segment of an anomalous coronary artery of aortic origin. Anomalous aortic origin of a coronary artery (AAOCA) from an opposite sinus of Valsalva is a rare congenital abnormality with an associated risk of sudden death from ischemia. Although there are myriad configurations of the coronary anatomy both within and without the range of normal variation, AAOCA is one of the relatively more common abnormal configurations. With this anomaly, the left coronary artery ostium lies within with the right sinus of Valsalva and then courses within the wall of the aorta. Conversely, the right coronary ostium lies within the left sinus of Valsalva and courses intramurally between the aorta and the pulmonary artery. The prevalence of anomalous coronaries arising from the opposite sinus of Valsalva is difficult to determine because patients may be asymptomatic, and even those patients who are asymptomatic may suffer sudden cardiac death attributable to the anomalous coronary. Defining incidence is further complicated by the fact that there are different incidence rates from pathologic,1Alexander R.W. Griffith G.C. Anomalies of the coronary arteries and their clinical significance.Circulation. 1956; 14: 800-805Crossref PubMed Scopus (320) Google Scholar, 2Kragel A.H. Roberts W.C. Anomalous origin of either the right or left main coronary artery from the aorta with subsequent coursing between aorta and pulmonary trunk: Analysis of 32 necropsy cases.Am J Cardiol. 1988; 62: 771-777Abstract Full Text PDF PubMed Scopus (273) Google Scholar, 3Frescura C. Basso C. Thiene G. et al.Anomalous origin of coronary arteries and risk of sudden death: A study based on an autopsy population of congenital heart disease.Hum Pathol. 1998; 29: 689-695Abstract Full Text PDF PubMed Scopus (420) Google Scholar angiographic,4Yamanaka O. Hobbs R.E. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography.Cathet Cardiovasc Diagn. 1990; 21: 28-40Crossref PubMed Scopus (1655) Google Scholar, 5Yildiz A. Okcun B. Peker T. et al.Prevalence of coronary artery anomalies in 12,457 adult patients who underwent coronary angiography.Clin Cardiol. 2010; 33: E60-E64Crossref PubMed Scopus (95) Google Scholar and echocardiographic6Dawn B. Talley J.D. Prince C.R. et al.Two-dimensional and Doppler transesophageal echocardiographic delineation and flow characterization of anomalous coronary arteries in adults.J Am Soc Echocardiogr. 2003; 16: 1274-1286Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar studies. The incidence in people undergoing coronary catheterization is usually quoted to be 1%, although incidence is estimated to be much less in the general population.7Angelini P. Coronary artery anomalies: An entity in search of an identity.Circulation. 2007; 115: 1296-1305Crossref PubMed Scopus (540) Google Scholar, 8Angelini P. Velasco J.A. Flamm S. Coronary anomalies: Incidence, pathophysiology, and clinical relevance.Circulation. 2002; 105: 2449-2454Crossref PubMed Scopus (742) Google Scholar Despite being relatively uncommon, these anomalous coronary arteries that originate in the opposite sinus of Valsalva are very often fatal and are believed to be the second most common cause of sudden cardiac death in young athletes.9Maron B.J. Thompson P.D. Puffer J.C. et al.Cardiovascular preparticipation screening of competitive athletes. A statement for health professionals from the Sudden Death Committee (clinical cardiology) and Congenital Cardiac Defects Committee (cardiovascular disease in the young), American Heart Association.Circulation. 1996; 94: 850-856Crossref PubMed Scopus (538) Google Scholar Although the pathophysiology of sudden cardiac death in patients with AAOCA is incompletely elucidated, it is principally the result of an insufficient coronary blood flow and myocardial ischemia. The previously popular hypothesis that the artery is subject to intermittent external compression from its course between the great vessels seems to be an unlikely mechanism, and new theories have emerged.10Jaggers J. Lodge A.J. Surgical therapy for anomalous aortic origin of the coronary arteries.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2005; : 122-127Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 11Fedoruk L.M. Kern J.A. Peeler B.B. et al.Anomalous origin of the right coronary artery: Right internal thoracic artery to right coronary artery bypass is not the answer.J Thorac Cardiovasc Surg. 2007; 133: 456-460Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar One such theorized mechanism of insufficient coronary perfusion is due to the acute angle of the anomalous coronary ostium. With increased intraluminal pressure in the aorta, such as during exercise, the intimal flap of an acutely angled coronary takeoff can obstruct the ostium during diastole. When the intramural segment of the coronary is at the commissural level, increased intra-aortic pressure can displace the commissure into the ostium, thus obstructing coronary flow.10Jaggers J. Lodge A.J. Surgical therapy for anomalous aortic origin of the coronary arteries.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2005; : 122-127Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Other hypotheses include obstruction of the intramural portion of the (frequently stenotic) coronary artery with increased intraluminal aortic pressure during strenuous activity, arterial spasm, and arrhythmia related to multiple minor ischemic insults.12Davies J.E. Burkhart H.M. Dearani J.A. et al.Surgical management of anomalous aortic origin of a coronary artery.Ann Thorac Surg. 2009; 88 (discussion 847-848): 844-847Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar Patients with AAOCA commonly present with sudden cardiac death, and the anomaly is discovered on autopsy, as it is not uncommon for those patients to be asymptomatic. For those patients with AAOCA who do report symptoms or have signs, and are subsequently found to have AAOCA, the most common symptoms are angina, exertional dyspnea, syncope, and arrhythmia.7Angelini P. Coronary artery anomalies: An entity in search of an identity.Circulation. 2007; 115: 1296-1305Crossref PubMed Scopus (540) Google Scholar, 10Jaggers J. Lodge A.J. Surgical therapy for anomalous aortic origin of the coronary arteries.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2005; : 122-127Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Although sudden cardiac death is the most common presenting symptom in younger patients with AAOCA, older patients are more likely to present with the aforementioned symptoms, which are often related to the onset of hypertension.7Angelini P. Coronary artery anomalies: An entity in search of an identity.Circulation. 2007; 115: 1296-1305Crossref PubMed Scopus (540) Google Scholar Multiple surgical strategies to ameliorate possible ischemia from an AAOCA have been proposed, including coronary reimplantation,13Di Lello F. Mnuk J.F. Flemma R.J. et al.Successful coronary reimplantation for anomalous origin of the right coronary artery from the left sinus of Valsalva.J Thorac Cardiovasc Surg. 1991; 102: 455-456Abstract Full Text PDF PubMed Google Scholar coronary artery bypass grafting (CABG),14Reul R.M. Cooley D.A. Hallman G.L. et al.Surgical treatment of coronary artery anomalies: Report of a 37 1/2-year experience at the Texas Heart Institute.Tex Heart Inst J. 2002; 29: 299-307PubMed Google Scholar and unroofing of the intramural segment.10Jaggers J. Lodge A.J. Surgical therapy for anomalous aortic origin of the coronary arteries.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2005; : 122-127Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 11Fedoruk L.M. Kern J.A. Peeler B.B. et al.Anomalous origin of the right coronary artery: Right internal thoracic artery to right coronary artery bypass is not the answer.J Thorac Cardiovasc Surg. 2007; 133: 456-460Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar, 12Davies J.E. Burkhart H.M. Dearani J.A. et al.Surgical management of anomalous aortic origin of a coronary artery.Ann Thorac Surg. 2009; 88 (discussion 847-848): 844-847Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 15Mustafa I. Gula G. Radley-Smith R. et al.Anomalous origin of the left coronary artery from the anterior aortic sinus: A potential cause of sudden death. Anatomic characterization and surgical treatment.J Thorac Cardiovasc Surg. 1981; 82: 297-300PubMed Google Scholar, 16Mavroudis C. Mavroudis C.D. Jacobs J.P. Repair techniques for anomalous aortic origins of the coronary arteries.Cardiol Young. 2015; 25: 1546-1560Crossref PubMed Scopus (3) Google Scholar, 17Mainwaring R.D. Reddy V.M. Reinhartz O. et al.Surgical repair of anomalous aortic origin of a coronary artery.Eur J Cardiothorac Surg. 2014; 46: 20-26Crossref PubMed Scopus (45) Google Scholar, 18Romp 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 (discussion 595-586): 589-595Abstract Full Text Full Text PDF PubMed Scopus (163) Google Scholar Coronary reimplantation is technically challenging; yet, in some instances, reimplantation of the coronary is the safest method of ameliorating the effects of the anomalous coronary. This approach is generally used when the commissure overlies the intramural segment or if the intramural portion is likely to be compressed by the pulmonary artery, and a coronary button with the intramural segment is then mobilized.19Dekel H. Hickey E.J. Wallen J. et al.Repair of anomalous aortic origin of coronary arteries with combined unroofing and unflooring technique.J Thorac Cardiovasc Surg. 2015; 150: 422-424Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar CABG is another viable option for relieving the ischemia associated with intramural segments of anomalous coronaries; however, it is not uncommon for grafts to become occluded because of competitive flow through the native coronary vessels, which are minimally obstructed at rest.10Jaggers J. Lodge A.J. Surgical therapy for anomalous aortic origin of the coronary arteries.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2005; : 122-127Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Furthermore, when internal mammary arteries are used to graft anomalous segments of coronaries, the initial flow from an internal mammary arterial graft is likely insufficient to compensate for a ligated native vessel, leading to myocardial ischemia in mostly young and otherwise healthy adults.11Fedoruk L.M. Kern J.A. Peeler B.B. et al.Anomalous origin of the right coronary artery: Right internal thoracic artery to right coronary artery bypass is not the answer.J Thorac Cardiovasc Surg. 2007; 133: 456-460Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar Outcomes with each of these approaches have varied; however, surgical unroofing has produced consistently good outcomes with few short- or long-term complications.11Fedoruk L.M. Kern J.A. Peeler B.B. et al.Anomalous origin of the right coronary artery: Right internal thoracic artery to right coronary artery bypass is not the answer.J Thorac Cardiovasc Surg. 2007; 133: 456-460Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar, 12Davies J.E. Burkhart H.M. Dearani J.A. et al.Surgical management of anomalous aortic origin of a coronary artery.Ann Thorac Surg. 2009; 88 (discussion 847-848): 844-847Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 18Romp 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 (discussion 595-586): 589-595Abstract Full Text Full Text PDF PubMed Scopus (163) Google Scholar The technique is presented on the following pages (Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6, Figure 6, Figure 6, Figure 6, Figure 6, Figure 6, Figure 7, Figure 8).Figure 2(A) In this anterior-posterior view of the heart, the course of the coronaries along the external surface of the heart appears grossly normal; however, the right coronary artery ostium is located within the left sinus of Valsalva, with the proximal portion of the coronary traveling within the wall of the ascending aorta and then coursing normally along the acute margin of the heart. Although isolated coronary anomalies are relatively rare and is thought to occur in only about 1% of the population, the incidence of anomalous aortic origin of coronary arteries from the opposite sinus of Valsalva is even more rare, with the incidence of the right coronary arising from the left sinus of Valsalva approximated at 0.05%-0.1%.1Alexander R.W. Griffith G.C. Anomalies of the coronary arteries and their clinical significance.Circulation. 1956; 14: 800-805Crossref PubMed Scopus (320) Google Scholar The true incidence of the defect, however, is unknown, as there is a selection bias toward patients who have ischemic symptoms and are thus are more likely to undergo cardiac catheterization and identify an anomalous coronary. (B) The left main coronary artery ostium is located more anteriorly within the right sinus of Valsalva. To reach its normal course along the obtuse margin and the anterior surface of the heart, the left main coronary artery lies within the aortic wall and then emerges on the surface of the heart, and normally divides into the left circumflex and the left anterior descending coronary arteries. The incidence of a left main coronary artery from the right sinus of Valsalva is even less than that of a right coronary artery arising from the left sinus of Valsalva, estimated at 0.03%-0.05%.1Alexander R.W. Griffith G.C. Anomalies of the coronary arteries and their clinical significance.Circulation. 1956; 14: 800-805Crossref PubMed Scopus (320) Google Scholar Despite being less common, the mortality associated with a left main coronary artery from the right sinus is reported to be greater than that associated with a right coronary artery arising from the left sinus of Valsalva.20Taylor A.J. Byers J.P. Cheitlin M.D. et al.Anomalous right or left coronary artery from the contralateral coronary sinus: “high-risk” abnormalities in the initial coronary artery course and heterogeneous clinical outcomes.Am Heart J. 1997; 133: 428-435Abstract Full Text Full Text PDF PubMed Scopus (298) Google Scholar Pathologic variables that may account for these mortality differences include longer intramural courses, coursing of the coronary between the aorta and the pulmonary artery, an acute takeoff of the coronary relative to the aorta, and a slit-like coronary ostium.20Taylor A.J. Byers J.P. Cheitlin M.D. et al.Anomalous right or left coronary artery from the contralateral coronary sinus: “high-risk” abnormalities in the initial coronary artery course and heterogeneous clinical outcomes.Am Heart J. 1997; 133: 428-435Abstract Full Text Full Text PDF PubMed Scopus (298) Google ScholarView Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3The initial operative steps in the unroofing of an anomalous coronary artery include standard cannulation techniques for a cardiopulmonary bypass. Following a median sternotomy and the creation of a pericardial well, purse string sutures are placed in the distal ascending aorta, and an aortotomy is made into which an aortic cannula is placed and secured with Rummel tourniquets. Depending on what concomitant operations, if any, are being performed with the unroofing of the coronary artery, venous cannulation with a dual-stage venous cannula through a right atriotomy can be established, and the cannula can be secured with a Rummel tourniquet around a purse string suture placed in the right atrium. It is our practice to place this purse string around the right atrial appendage and to create the atriotomy by using Metzenbaum scissors to cut off the tip of the right atrial appendage. Bicaval venous cannulation via the superior and the inferior vena cavae (not pictured) can also be used, if necessary, for atrial exposure in concomitant operations. Following the establishment of aortic and venous cannulations, an aortic root vent is placed in the ascending aorta proximal to the aortic cannula to allow drainage of the aortic root and the administration of antegrade cardioplegia. A left ventricular venting cannula is placed in the right superior pulmonary vein to allow adequate exposure and drainage of the left ventricle. A retrograde cardioplegia catheter is placed in the coronary sinus for additional cardioplegia protection of the myocardium. Once the patient has been adequately anticoagulated, cardiopulmonary bypass can then be initiated, and the patient is cooled to 32-34°C. The cross clamp can then be applied to the ascending aorta between the root vent and the aortic cannula. Cold-blood retrograde and anterograde cardioplegia is used to arrest the heart and is repeated approximately every 20 minutes to reinforce cardiac arrest throughout the course of the operation.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4Following a cardioplegic arrest of the heart, the aortic root vent can be removed, and a transverse aortotomy is made approximately 2 cm distal to the sinotubular junction. The aortotomy is then extended parallel to the annulus of the aortic valve. A stay suture can be placed in the distal portion of the divided ascending aorta to allow adequate visualization of the aortic root (not pictured). With the aortic root opened, there are 2 orifices noted within the right sinus of Valsalva, a normal-appearing right coronary ostium and a small slit-like ostium for the left coronary artery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Once the 2 ostia have been definitively identified within the aortic root, a small right angle clamp is gently placed into the ostia of the anomalously located at the left coronary artery. With the clamp inside the coronary, a #15 blade is used to unroof the overlying common wall of the coronary artery and the aorta. About 1.0-1.5 cm of the intramural coronary is unroofed.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6(A) In some instances, the intramural portion of the coronary may cross the from 1 aortic sinus into the next by traversing the commissural plane, rather than being completely above the commissure, as illustrated with an anomalous left coronary artery in this figure. A typical unroofing procedure in which the length of the intramural portion is incised is contraindicated as that would disrupt the aortic valve leaflets. LAD = left anterior descending coronary artery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6Continued (B) In these instances, the commissure is detached, and the intramural portion of the coronary is unroofed.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6Continued (C) The detached commissure is then resuspended above the unroofed intramural segment with a pledgetted suture.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6Continued (D) When the commissure crosses only a small portion of the intramural coronary segment, the unroofing can be carried out on either side of the commissure, thus leaving the commissure intact and not disturbing leaflet motion.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6Continued (E) Reimplantation of the coronary into the correct sinus is another viable option when the anomalous segment is closely related to the commissure. The intramural portion of the artery is unroofed, and the proximal left coronary is mobilized.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6Continued (F) The left coronary is reimplanted into the correct left sinus. The aortic wall defect remaining after the excision of the coronary button can be patched with bovine pericardium or a similar patch material.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 7After the intramural segment of the anomalous coronary artery is unroofed, a neo-ostium is created in the correct sinus of Valsalva. To prevent an intimal dissection at this neo-orifice, interrupted tacking sutures using a 7-0 monofilament suture are placed circumferentially around the ostium, thus securing the coronary intima to the aortic wall.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 8Following completion of the unroofing and any other concomitant procedures, the aortotomy is closed in 2 layers with a running monofilament suture. The aortic root vent should also be replaced to allow adequate deairing of the heart before the removal of the cross clamp. While completing the aortotomy closure, the perfusion team can begin to rewarm the patient to prepare for separation from the cardiopulmonary bypass. The left ventricular and aortic root vents and the retrograde cardioplegia catheter can be removed, and weaning from bypass can then begin. Once the patient is weaned from bypass, the patient can be decannulated in the standard fashion.View Large Image Figure ViewerDownload Hi-res image Download (PPT) An estimated 5.6% of the American population has some sort of congenital coronary anomaly,8Angelini P. Velasco J.A. Flamm S. Coronary anomalies: Incidence, pathophysiology, and clinical relevance.Circulation. 2002; 105: 2449-2454Crossref PubMed Scopus (742) Google Scholar and although not all of these anomalies require surgical intervention, AAOCA is a very often lethal subtype of anomalous coronary that should be corrected when discovered in symptomatic patients. Kaushal and colleagues have noted that patients who are symptomatic are more likely to have a longer intramural course of the coronary, which could prompt earlier intervention or determine the method of surgical repair.21Kaushal S. Backer C.L. Popescu A.R. et al.Intramural coronary length correlates with symptoms in patients with anomalous aortic origin of the coronary artery.Ann Thorac Surg. 2011; 92 (discussion 991-982): 986-991Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar The timing of surgery in asymptomatic patients, however, remains somewhat controversial, and the risk of sudden cardiac death must be weighed against the risk of surgical intervention and potential subsequent long-term complications. Notably, the risk of sudden cardiac death is much higher in patients with an anomalous left main coronary artery than in those with an anomalous right coronary artery, thus making it more prudent to pursue elective surgery in patients with that anatomical configuration. Most, however, will wait until adolescence, as sudden cardiac death in children with AAOCA is rare.10Jaggers J. Lodge A.J. Surgical therapy for anomalous aortic origin of the coronary arteries.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2005; : 122-127Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Several different repair methods for AAOCA are used, and the method that is used generally depends on anatomical variables, as well as surgeon comfort with a given procedure.14Reul R.M. Cooley D.A. Hallman G.L. et al.Surgical treatment of coronary artery anomalies: Report of a 37 1/2-year experience at the Texas Heart Institute.Tex Heart Inst J. 2002; 29: 299-307PubMed Google Scholar CABG is an option for rerouting coronary blood flow around the intramural segments; however, performing bypass grafts without ligation of the native vessel may lead to an eventual occlusion of the patent native coronaries because of competitive flow. In addition, using internal mammary arteries as bypass conduits results in competitive flow with the native coronaries, thus placing the internal mammary artery at risk of disuse atrophy and eventual occlusion. Using the internal mammary artery also limits revascularization options for patients in the future.22Krasuski R.A. Magyar D. Hart S. et al.Long-term outcome and impact of surgery on adults with coronary arteries originating from the opposite coronary cusp.Circulation. 2011; 123: 154-162Crossref PubMed Scopus (105) Google Scholar Nevertheless, CABG remains a viable option, especially in older patients and in those with an anatomy prohibitive for safe reimplantation or unroofing. Coronary reimplantation into the correct sinus is another option for the repair of anomalous coronaries; however, the procedure is technically demanding and is therefore limited to patients with a specific anatomy, including a lack of a slit-like orifice, an intramural segment, or a common ostium. Reimplantation may also be required when an intramural segment disrupts the commissure and a resuspension of the commissure would create aortic insufficiency.22Krasuski R.A. Magyar D. Hart S. et al.Long-term outcome and impact of surgery on adults with coronary arteries originating from the opposite coronary cusp.Circulation. 2011; 123: 154-162Crossref PubMed Scopus (105) Google Scholar Finally, unroofing of the intramural segment of anomalous coronaries has been performed with relatively few short- or long-term complications, and it does appear to relieve the ischemia associated with the anomalous intramural course of coronaries.11Fedoruk L.M. Kern J.A. Peeler B.B. et al.Anomalous origin of the right coronary artery: Right internal thoracic artery to right coronary artery bypass is not the answer.J Thorac Cardiovasc Surg. 2007; 133: 456-460Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar, 12Davies J.E. Burkhart H.M. Dearani J.A. et al.Surgical management of anomalous aortic origin of a coronary artery.Ann Thorac Surg. 2009; 88 (discussion 847-848): 844-847Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 17Mainwaring R.D. Reddy V.M. Reinhartz O. et al.Surgical repair of anomalous aortic origin of a coronary artery.Eur J Cardiothorac Surg. 2014; 46: 20-26Crossref PubMed Scopus (45) Google Scholar, 18Romp 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 (discussion 595-586): 589-595Abstract Full Text Full Text PDF PubMed Scopus (163) Google Scholar Using the techniques described herein, surgical unroofing results in a durable and successful amelioration of coronary ischemia and its associated signs and symptoms for a majority of patients.