Ann Thorac Surg 2001;72:1768-1769
© 2001 The Society of Thoracic Surgeons
How to do it
Extended unroofing procedure for creation of a new ostium for anomalous left coronary artery
Hiroyuki Nakajima, MD*a,
Toshikatsu Yagihara, MDa,
Hideki Uemura, MDa,
Youichi Kawahira, MDa,
Yoshiro Yoshikawa, MDa
a Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan
Accepted for publication June 11, 2001.
* Address reprint requests to Dr Nakajima, Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan
e-mail: hnakajim{at}hsp.ncvc.go.jp
 |
Abstract
|
|---|
A modified procedure to create an alternative ostium for the left coronary artery was successfully carried out in a patient having anomalous origin of the left coronary artery from the right coronary sinus of the aorta. The proximal portion of the artery had an intramural course. The newly constructed orifice was widely patent and functioning well 44 months later, without episodes of myocardial ischemia or aortic regurgitation.
|
Introduction
|
|---|
To prevent myocardial ischemia and sudden death, surgical intervention remains the most feasible treatment of patients with an anomalous origin of the coronary arteries taking an intramural course within the aortic wall. A variety of operative procedures have been reported, including coronary arterial bypass grafting, creation of an alternative orifice for the coronary arteries, and aortic root replacement. A new modification of ostial creation for the left coronary artery (LCA) was successfully carried out in one of our patients.
|
Technique
|
|---|
A 15-year-old boy had repeated episodes of syncope occurring during or immediately after exercise. The cause of the syncope was unknown. The last episode was critical, as the boy went into a shock with myocardial infarction. Fortunately, he was resuscitated, and an electrocardiogram demonstrated ST-segment depression in some leads.
The patient was eventually transferred to our institution. Echocardiography revealed that two coronary arteries originated from separate orifices of their own within the right coronary sinus of the aortic Valsalva sinus, and the LCA was coursing intramurally within the aortic wall between the ascending aorta and the pulmonary trunk. Coronary angiography confirmed these findings. The tortuous left main trunk proved to be mildly obstructed by the pulmonary trunk.
The surgical procedure was carried out with the patient on standard cardiopulmonary bypass and under cardiac arrest induced by antegrade infusion of cold crystaloid cardioplegic solution. An oblique incision was made on the aortic root and extended toward the facing commissure. The orifice of the LCA was present unequivocally within the right coronary sinus below the sinotubular junction and seemed sufficiently large, its shape being oval. Guided by a 2.5-mm diameter probe, a small fenestration was made between the intramural course of the LCA and the left coronary sinus. Subsequently, the fenestration was enlarged by extending the incision posteriorly for the aortic sinus and longitudinally for the extramural portion of the LCA (Fig 1). In addition, a proximal portion of the LCA was carefully dissected for mobilization. Several stitches were placed in interrupted fashion for fixing the incised LCA to the aortic sinus. Thus the alternative orifice for the LCA became 6 mm in diameter. The original ostium and intramural tunnel of the LCA was left open. Removing the patient from bypass went smoothly, with no findings of myocardial ischemia.
View larger version (24K):
[in this window]
[in a new window]
|
Fig 1. Schema for the operative procedure. (A) A fenestration was made between the intramural segment of the left coronary artery and the left coronary sinus of the aorta. The incision was extended posteriorly for the aortic sinus and longitudinally toward the extramural portion of the left coronary artery. The proximal portion of the left main trunk was carefully dissected for mobilization. (B) A new ostium was created sufficiently large by fixing the incised left coronary artery to the aortic sinus using 6-0 sutures in an interrupted fashion.
|
|
The postoperative course was uneventful. Coronary angiography 12 months after the procedure illustrated that the newly created orifice was unobstructedly patent. No aortic regurgitation was noted. The patient is doing very well after 44 months, with no symptoms of myocardial ischemia.
|
Comment
|
|---|
An anomalous LCA origin arising from the right coronary sinus and coursing between the ascending aorta and the pulmonary trunk is known to pose potential risks of myocardial ischemia and sudden death. Surgical treatments have been recommended for the lesion, although precise diagnosis of this malformation remains rather difficult in living patients [1]. In general, such critical episodes occur unexpectedly during or immediately after exercise. Mustafa and coworkers [2] commented that the mechanism causing the lethal events was composed of three aspects: acute angle at the origin of the LCA in relation to the aortic wall, stretch of the intramural segment of the LCA, and compression produced by the facing commissure. Various operative procedures have been reported that can cancel these factors.
Coronary arterial bypass grafting is obviously attractive [3, 4] because the procedure is one of the standard techniques in cardiac surgery. Use of the internal thoracic artery has proven justifiable even in small children [5]. The surgeon should pay attention, nonetheless, to two issues when coronary arterial bypass is to be employed in the setting of abnormal origin of the LCA. First, it remains unclear whether the solitary internal thoracic artery can provide a sufficient amount of blood flow for the entire LCA system when the oxygen demand of the heart is considerably high in active young patients immediately after exercise. Second, flow competition can occur after coronary arterial bypass [3] between the proximal portion of the native LCA and the bypass graft, because stenosis of the proximal LCA is basically less significant at rest. Regression of the internal thoracic arterial graft can progress after the procedure.
In these respects, creation of an alternative ostium for the LCA seems more efficient, as such a procedure provides almost definitive repair of the malformation [6, 7]. To make the new orifice sufficiently large, some technical devices might be needed. Cutting back the intramural segment of the LCA can be one surgical option. Detachment and refixation of the facing commissure, if employed, may produce the postoperative problem of aortic regurgitation. Our modification did not affect the aortic valve. In addition, this modification can readily be employed regardless of the length of the intramural segment of the coronary artery. The wide orifice has remained functioning well for 44 months without progressive organic orificial stenosis. We conclude that our modification is one of the surgical interventions of choice in patients with anomalous origin of the LCA.
|
References
|
|---|
-
Kragel A.H., Roberts W.C. Amonalous 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;62:771-777.[Medline]
-
Mustafa I., Gula G., Radley-Smith R., Durrer S., Yacoub M. Anomalous origin of the left coronary artery form the anterior aortic sinus: a potential cause of death. J Thorac Carviovasc Surg 1981;82:297-300.
-
Fernandes E.D., Kadivar H., Hallman G.L. Congenital malformation of the coronary arteries: the Texas Heart Institute experience. Ann Thorac Surg 1992;54:732-740.[Abstract]
-
Wolf T., Bolotin G., Ammar R., Uretzky G. Anomalous origin of the left coronary artery: anatomical correction and concomitant LIMA-LAD grafting. Eur J Cardiothorac Surg 1999;15:209-212.[Abstract/Free Full Text]
-
Yoshikawa Y., Yagihara T., Kameda Y., et al. Result of surgical treatments in patients with coronary arterial disease after Kawasaki disease. Eur J Cardiothorac Surg 2000;17:515-519.[Abstract/Free Full Text]
-
van Son J.A.M., Mohr F.W. Modified unroofing procedure in anomalous aortic origin of left or right coronary artery. Ann Thorac Surg 1997;64:568-569.[Abstract/Free Full Text]
-
Rinaldi R.G., Carballido J., Giles R., Toro E.D., Porro R. Right coronary artery with anomalous origin and slit ostium. Ann Thorac Surg 1994;58:828-832.
This article has been cited by other articles:
|
|
|
|
 
S. K. Gandhi, F. A. Pigula, and R. D. Siewers
Intramural left coronary artery associated with right ventricular outflow tract obstruction
J. Thorac. Cardiovasc. Surg.,
March 1, 2003;
125(3):
729 - 730.
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
