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• W2897870995 abstract "It has become increasingly evident that anomalous aortic origin of a coronary artery is considered as an important anatomic anomaly in adolescents and adults. The question is whether or not surgical repair should be performed in asymptomatic patients. Previous reports showed that the numbers of asymptomatic patients who result in a sudden cardiac death are not negligible. Another reason to proceed to surgical intervention is the improvement in understanding this unique anatomy and the refinement of surgical techniques that brought the satisfied outcomes. Physiologic repair, that is, coronary artery bypass grafting was used to be the first choice of surgery; however, anatomic repair, such as coronary implantation and repair of intramural coronary artery is considered favorable in adolescents as “radical” oppose to “palliative” repair. We report our technique to relieve the intramural coronary artery based on the experience in arterial switch operation performed in neonates. It has become increasingly evident that anomalous aortic origin of a coronary artery is considered as an important anatomic anomaly in adolescents and adults. The question is whether or not surgical repair should be performed in asymptomatic patients. Previous reports showed that the numbers of asymptomatic patients who result in a sudden cardiac death are not negligible. Another reason to proceed to surgical intervention is the improvement in understanding this unique anatomy and the refinement of surgical techniques that brought the satisfied outcomes. Physiologic repair, that is, coronary artery bypass grafting was used to be the first choice of surgery; however, anatomic repair, such as coronary implantation and repair of intramural coronary artery is considered favorable in adolescents as “radical” oppose to “palliative” repair. We report our technique to relieve the intramural coronary artery based on the experience in arterial switch operation performed in neonates. Anomalous aortic origin of a coronary artery (AAOCA) is an extremely rare congenital cardiac defect that has been reported approximately 0.1%-0.2% of incidence.1Basso C. Maron B.J. Corrado D. et al.Clinical profile of congenital coronary artery anomalies with origin from the wrong aortic sinus leading to sudden death in young competitive athletes.J Am Coll Cardiol. 2000; 35: 1493-1501Crossref PubMed Scopus (895) Google Scholar, 2Romp 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 (163) Google Scholar In this anomaly, the left coronary artery ostium arises from the right coronary sinus, typically runs within the aortic wall (= intramural course), and then leave the aortic wall from the appropriate coronary sinus. This anatomic configuration is also seen in the right coronary artery. The slit-like ostium, intramural portion of the coronary artery, and acute takeoff angle at the exit of the aortic wall can cause myocardial ischemia on vigorous exercise, potentially resulting in lethal event. It is not uncommon for these patients to be asymptomatic and the patients usually present with sudden cardiac death, and AAOCA is diagnosed with autopsy. Hence, sudden death is the most important clinical precipitation even in asymptomatic young people, occurring 25%-54% of those diagnosed as AAOCA.3Maron B.J. Shirani J. Fau-Poliac L.C. et al.Sudden death in young competitive athletes. Clinical, demographic, and pathological profiles.JAMA. 1996; 276 (17): 199-204Crossref PubMed Google Scholar, 4Benson P.A. Fau-Lack A.R. Lack A.R. Anomalous aortic origin of left coronar artery. Report of two cases.Arch Pathol. 1968; 86: 214-216PubMed Google Scholar Typical symptoms, if presented any, are angina, exertional dyspnea, syncope, or even musculoskeletal chest pain. Frommelt et al showed that AAOCA could be prospectively diagnosed by transthoracic echocardiogram in 9 out of 10 patients.5Frommelt P.C. Frommelt M.A. Fau-Tweddell J.S. et al.Prospective echocardiographic diagnosis and surgical repair of anomalous origin of a coronary artery from the opposite sinus with an interarterial course.J Am Coll Cardiol. 2003; 42: 148-154Crossref PubMed Scopus (154) Google Scholar The improvement in diagnosis raised a question whether or not surgical repair should be performed for those who are asymptomatic. Various surgical managements have been reported. Unroofing of the intramural segment is considered as ideal anatomic repair.6Mavroudis 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, 7Mustafa I. Fau-Gula G. Gula G. 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, 8Davies J.E. Burkhart H.M. Fau-Dearani J.A. et al.Surgical management of anomalous aortic origin of a coronary artery.Ann Thorac Surg. 2009; 88: 844-847Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 9Fedoruk L.M. Kern J.A. Fau-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 Coronary implantation is indicated when the commissure overlies the intramural segment or the intramural portion is compressed by the pulmonary trunk.10Dekel 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, 11Di Lello F. Fau-Mnuk J.F. Mnuk J.F. 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 can be the first choice in adolescents and adults, but a care should be taken because there would be competitive flow through the native coronary artery if no stenosis and it is not rare for the graft to be occluded.12Reul R.M. Cooley D.A. Fau-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, 13Jaggers J. Lodge A.J. Surgical therapy for anomalous aortic origin of the coronary arteries.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2005; 8: 122-127Abstract Full Text Full Text PDF Scopus (33) Google Scholar Preoperative evaluation is of prime importance in AAOCA. Transesophageal echocardiogram helps to clearly demonstrate the abnormal origin of the coronary artery. Computed tomography (CT) and cardiac magnetic resonance are alternative modalities to diagnose the AAOCA. Surgical indication in asymptomatic pediatric patients is controversial; however, it should be considered in teenager as the occurrence of coronary ischemia and subsequent lethal event increases. Preoperative CT scan showed that the ostium of the left coronary artery locates at the right coronary sinus. The left coronary artery then runs through the aortic wall, that is, intramural course, and arises from the aorta at the left coronary sinus (Fig. 1). The surgical approach is usually via median sternotomy with standard cardiopulmonary bypass. Preparation of the legs is considered for possible harvest of saphenous vein when need a coronary artery bypass grafting. Cardiopulmonary bypass is commenced with ascending aortic and right atrial cannulation. Figure 2A shows the heart looking from the top. There are 2 coronary ostium in the right coronary sinus. Figure 2B shows intramural course of the left coronary artery. The intramural portion of the left coronary artery is narrowed down. Figure 3A: After aortic cross-clamping, the cardioplegia is given and cardiac arrest is obtained. Aortotomy is performed transversely and the incision is extended to the noncoronary sinus for a better exposure. After aortotomy, the coronary ostium is confirmed. The ostium of the left coronary artery is usually narrowed, slit-like shape (Fig. 3B). Detach of the commissure (Fig. 4A): The commissure between the left and the right coronary cusp is temporary detached. Using a fine knife, the commissure is gently detached from the aortic wall until the level of where the left coronary artery runs. The use of coronary probe guides where the left coronary artery runs (Fig. 4B). The elastic probe is recommended to avoid the injury of the coronary artery. Cut back the intramural portion (Fig. 4C): With a guide of coronary probe, the intramural portion of the left coronary artery is cut back using the fine scissors. It is easy to find how far the intramural portion should be opened when using elastic probe as it changes its angle. The probe becomes perpendicular to the aortic wall and that is where the coronary artery arises from the aorta (Fig. 4D). The detached commissure is tacked to the aortic wall. Elastic coronary probe (Fig. 4E): We prefer to use an elastic coronary probe (BVI probe, Synovis Surgical Innovations, St. Paul, MN) because of less risk of injury and great visual exposure of coronary course. Figure 5A: The left coronary artery arises from the right coronary sinus and runs between the aortic and pulmonary trunk, causing anatomic compression. Figure 5B: The coronary button is harvested from the right coronary sinus. It is important to take larger coronary button as much as possible. Figure 5B: The incision is then made at the left coronary sinus where the coronary button will be implanted. The incision is reversed J-shape and the incision should be stayed above the commissure level to prevent the distortion of the sinus valsalva and possible aortic valve regurgitation. Figure 5C: The coronary button is implanted using “trap-door” technique. Because of “trap door technique,” the reimplanted coronary button has “dog ear” and this can prevent the kink of the coronary artery. Figure 5D: The defect of the right coronary sinus is patched using the glutaraldehyde-treated autologous pericardium (Fig. 6).Figure 6Postoperative computed tomography.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Postoperative CT scan showed that the ostium of the left coronary artery locates at the left coronary sinus and is widely opened (Fig. 6). Repair of intramural coronary artery in terms of “unroofing” and “reimplantation” can be safely performed. This technique, if performed appropriately, can provide an “anatomically corrected” coronary artery and it does not have a risk of kinking of coronary artery seen in reimplantation technique. Because of relatively rare anomaly, further follow-up will be necessary." @default.
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• W2897870995 title "Repair of Intramural Coronary Artery in Anomalous Aortic Origin of a Coronary Artery" @default.
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