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Ann Thorac Surg 1997;64:568-569
© 1997 The Society of Thoracic Surgeons

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How To Do It

Modified Unroofing Procedure in Anomalous Aortic Origin of Left or Right Coronary Artery

Herzzentrum, University of Leipzig, Leipzig, Germany

Accepted for publication March 8, 1997.

	Abstract

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A modified technique is reported for unroofing of the intramurally coursing segment of the left main or right coronary artery with anomalous aortic origin. This technique avoids detachment and resuspension of the intercoronary commissure and thus lessens the risk of postoperative aortic valve regurgitation.

	Introduction

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Anomalous origin of the left main coronary artery (LCA) from the right sinus of Valsalva and, to a lesser extent, anomalous origin of the right coronary artery (RCA) from the left sinus of Valsalva is associated with myocardial ischemia and sudden death, particularly in young patients, with most cases reported at autopsy [1]. In the traditional technique, unroofing of the intramurally coursing segment of the LCA or RCA is facilitated by temporary detachment of the commissure between the left and right sinuses of Valsalva [2, 3]. This maneuver, however, has the disadvantage of the potential for postoperative aortic valve regurgitation [4]. We report an alternative technique of unroofing of the intramural coronary segment that avoids temporary detachment of the intercoronary commissure.

	Technique

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After cardiopulmonary bypass is established, cardioplegic solution is administered into the aortic root, and a transverse aortotomy is made with extension toward the noncoronary sinus. For unroofing of the anomalously coursing LCA, which usually originates from the right sinus in close proximity to the commissure between the left and right sinuses, a 1.0- or 1.5-mm coronary probe is passed from the ostium of the LCA toward the left sinus, thereby lifting the distal intramural segment of the LCA (Fig 1A). This maneuver facilitates incision of the LCA with a Beaver miniblade (Becton Dickinson, Franklin Lakes, NJ) close to its exit site from the aorta. The incision in the LCA is enlarged with coronary scissors to a total length of 8 to 10 mm, up to the exit site of the LCA. Subsequently, a neo-coronary ostium is created by suturing the circumference of the intima of the LCA to the intima of the aorta with continuous 7-0 polypropylene suture (Prolene; Ethicon, Inc, Somerville, NJ) (Fig 1B). A coronary probe is passed into the neo-coronary ostium to assess its patency. The unincised LCA segment on both sides of the intercoronary commissure is obliterated with a series of horizontal mattress sutures. The aortotomy is closed, the patient is weaned from cardiopulmonary bypass, and transesophageal echocardiography is rou-tinely performed to assess the adequacy of the repair and ventricular function, and to rule out aortic valve regurgitation. Repair of anomalous origin of the RCA from the left sinus is performed in an analogous manner (Fig 2).

View larger version (15K): [in this window] [in a new window]   Fig 1. . Modified unroofing procedure in anomalous origin of left main coronary artery (LCA) from the right sinus of Valsalva. (A) A small coronary probe is passed from the ostium of the LCA in the right sinus into the intramural segment of the LCA (black arrow). The distal intramural segment of the LCA is incised up to its exit site from the aortic wall (open arrow). (B) A neo-ostium is created by suturing the circumference of the coronary arterial wall to the intima of the left sinus. The unincised intramural segment of the LCA on either side of the commissure is obliterated with horizontal mattress sutures. (RCA = right coronary artery.)

View larger version (16K): [in this window] [in a new window]   Fig 2. . Modified unroofing procedure in anomalous origin of right coronary artery (RCA) from the left sinus of Valsalva. (A) A small coronary probe is passed from the ostium of the RCA in the left sinus into the intramural segment of the RCA (black arrow). The distal intramural segment of the RCA is incised up to its exit site from the aortic wall (open arrow). (B) A neo-ostium is created by suturing the circumference of the coronary arterial wall to the intima of the right sinus. The unincised intramural segment of the RCA on either side of the commissure is obliterated with horizontal mattress sutures (LCA = left coronary artery.)

	Comment

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With regard to operative technique, we prefer to unroof the intramural segment of the LCA or RCA and construct a neo-ostium in the respective sinus, as originally reported by Mustafa and colleagues [2] and Nelson-Piercy and co-workers [3], respectively. A similar operation has been reported for RCA with a slit ostium [5]. We believe that the creation of a wide neo-ostium from inside the aorta is highly effective because this procedure widens the coronary orifice and prevents compression of the intramural coronary artery segment, thereby eliminating the two principal causes of myocardial ischemia in anomalous aortic origin of the LCA or RCA. The traditional techniques of unroofing of the LCA or RCA have the disadvantage of temporary detachment of the intercoronary commissure with inherent risk of postoperative aortic valve regurgitation [4]. The modified technique as presented here has the distinct advantage of avoidance of temporary detachment of the intercoronary commissure, and therefore it may lessen the potential for aortic regurgitation. The reported modification was successfully performed in 1 patient (a 15-year-old boy) with anomalous origin of the LCA from the right sinus and 1 patient (a 12-year-old boy) with anomalous origin of the RCA from the left sinus. In both patients, at 11 and 4 months of follow-up, respectively, the clinical outcome was excellent with complete preservation of ventricular function and absence of aortic regurgitation.

A more expedient operation consists of reimplantation of the anomalous LCA or RCA [6]. This operation, however, may have an increased risk of kinking of the coronary artery or neo-ostial obstruction as a true button cannot be obtained because of the intramural course of the vessel [5]. Coronary artery bypass grafting, preferentially with the internal mammary artery, should be reserved for those patients who have atherosclerotic coronary artery disease.

	Footnotes

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Address reprint requests to Dr van Son, Herzzentrum, University of Leipzig, Russenstrasse 19, D-04289 Leipzig, Germany.

	References

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1. Kragel AH, Roberts WC. 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;62:771–7.[Medline]
2. Mustafa I, Gula G, Radley-Smith R, Durrer S, Yacoub M. 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;82:297–300.[Medline]
3. Nelson-Piercy C, Rickards AF, Yacoub MH. Aberrant origin of the right coronary artery as a potential cause of sudden death: successful anatomical correction. Br Heart J 1990;64:208–10.[Abstract/Free Full Text]
4. Phoon C, van Son JAM, Moore PA, et al. Anomalous left coronary artery arising from the right sinus of Valsalva with a right coronary arteriovenous malformation. Pediatr Cardiol (in press).
5. Garcia Rinaldi R, Carballido J, Giles R, Del Toro E, Porro R. Right coronary artery with anomalous origin and slit ostium. Ann Thorac Surg 1994;58:828–32.[Abstract/Free Full Text]
6. Fernandes ED, Kadivar H, Hallman GL, Reul GS, Ott DA, Cooley DA. Congenital malformations of the coronary arteries: the Texas Heart Institute experience. Ann Thorac Surg 1992;54:732–40.[Abstract/Free Full Text]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jacques A. M. van Son Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by van Son, J. A. M. Articles by Mohr, F. W. Search for Related Content PubMed PubMed Citation Articles by van Son, J. A. M. Articles by Mohr, F. W.