Surgical Therapy for Anomalous Aortic Origin of the Coronary Arteries

What is the Optimal Surgical Technique for Anomalous Aortic Origin of a Coronary Artery?

Anomalous aortic origin of a coronary artery (AAOCA) is associated with an increased risk of sudden cardiac death. Multiple surgical techniques have been developed to treat this anomaly. The optimal surgical technique to treat AAOCA is unclear but varies depending on the specific patient anatomy. We discuss 3 different techniques: unroofing of an intramural segment, coronary transection and reimplantation, and creation of a neo-ostium. Unroofing is optimal when the anomalous coronary has a long intramural segment that travels above the aortic valve. Creation of a neo-ostium by partially unroofing the coronary at the appropriate sinus should be considered if there is a long intramural segment that travels below the aortic valve. Coronary reimplantation is optimal if the intramural segment travels below the aortic valve but is not long enough for creation of a neo-ostium, or if there is a short or nonexistent intramural segment. Surgical technique should be individualized based on patient anatomy, and all potential anatomic culprits addressed.

Decision making in anomalous aortic origin of a coronary artery

INTRODUCTION

There are many uncertainties surrounding anomalous aortic origin of a coronary artery (AAOCA) including the pathophysiology of sudden cardiac death, how to best risk stratify patients, how to best evaluate patients, who would benefit from exercise restriction, who should undergo surgical intervention, and which operation to perform.

AREAS COVERED

The goal of this review is to provide a comprehensive but succinct overview of AAOCA to help clinicians with the difficult task of navigating optimal evaluation and treatment of an individual patient with AAOCA.

EXPERT OPINION

Beginning in year 2012, some of our authors proposed an integrated, multi-disciplinary working group which has become the standard management strategy for patients diagnosed with AAOCA. A multi-disciplinary team with a focus on shared decision-making with the patients/families is likely necessary to optimize outcomes. Long-term follow-up and research are needed to improve our understanding of AAOCA.

Imaging Features of Complications after Coronary Interventions and Surgical Procedures

Coronary artery interventions and surgical procedures are used in the treatment of coronary artery disease and some congenital heart diseases. Cardiac and noncardiac complications can occur at variable times after these procedures, with the clinical presentation ranging from asymptomatic to devastating symptoms. Invasive coronary angiography is the reference standard modality used in the evaluation of coronary arteries, with intravascular US and optical coherence tomography providing high-resolution information regarding the vessel wall. CT is the mostly commonly used noninvasive imaging modality in the evaluation of coronary artery intervention complications and allows assessment of the stent, lumen of the stent, lumen of the coronary arteries, and extracoronary structures. MRI is limited to the evaluation of the proximal coronary arteries but allows comprehensive evaluation of the myocardium, including ischemia and infarction. The authors review the clinical symptoms and pathophysiologic and imaging features of various complications of coronary artery interventions and surgical procedures. Complications of percutaneous coronary interventions are discussed, including restenosis, thrombosis, dissection of coronary arteries or the aorta, coronary wall rupture or perforation, stent deployment failure, stent fracture, stent infection, stent migration or embolism, and reperfusion injury. Complications of several surgical procedures are reviewed, including coronary artery bypass grafting, coronary artery reimplantation procedure (for anomalous origin from opposite sinuses or the pulmonary artery or as part of surgical procedures such as arterial switching surgery and the Bentall and Cabrol procedures), coronary artery unroofing, and the Takeuchi procedure. Online supplemental material is available for this article. ^©RSNA, 2021.

Malignant anomalous left coronary artery associated with acute coronary syndrome and subsequent post-operative secondary stenosis of the reimplanted anomalous left coronary artery

We present a case of a 14-year-old boy who presented with symptoms resulting from an anomalous left coronary artery. He underwent corrective surgery to reimplant the left coronary artery into the left coronary sinus. After 3 months, he developed new symptoms. On further investigation, a tight ostial stenosis of the left coronary artery was observed and the patient underwent left internal mammary artery to left anterior descending coronary artery bypass graft. This case showcases the importance of multi-modality imaging in the diagnosis of coronary artery anomalies and potential post-surgical complications.

Congenital coronary anomalies and surgical treatment

Coronary artery anomalies are not uncommon, occurring in 1.3% (range = 0.3-5.6%) of the population, and are often an incidental finding in asymptomatic patients. Approximately 20% of coronary anomalies have potential for life-threatening complication, including myocardial infarction, arrhythmia, or sudden death early in life or during adulthood. Coronary artery anomalies are composed of a wide variety of disorders. Some, such as anomalous location of a coronary ostium, duplication of coronary arteries, or multiple ostia, become clinically significant only when another cardiac surgical procedure is necessary, and generally, surgical correction is not required in these patients. On the other hand, the diagnosis of anomalous origin of left coronary artery from pulmonary artery or from the opposite sinus with inter-arterial course is an indication for operation. Some anomalies like coronary artery fistulas, myocardial bridging, and coronary aneurysm require operation only when they cause clinical symptoms. Coronary artery anomalies should be included in the differential diagnosis of anginal symptoms, myocardial infarction, arrhythmia, or heart failure, especially in young patients. Increased awareness of these pathologies will lead to earlier diagnosis and treatment of a potentially life-threatening condition.