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Ann Thorac Surg 2002;74:974
© 2002 The Society of Thoracic Surgeons

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Correspondence

Reply

^a Section of Cardiothoracic Surgery, Indiana University School of Medicine, Emerson Hall 215, 545 Barnhill Dr, Indianapolis, IN 46202 USA

e-mail: rodefeld{at}iupui.edu

To the Editor

The comments of Dr Garcia-Rinaldi are appreciated. In the report by his group [1], apparently none of the 8 adult patients undergoing surgical treatment of anomalous right coronary artery with slit ostium had anatomy in which the anomalous right coronary artery shares a common ostium with the left main coronary artery in the left coronary sinus adjacent to the right-left commissure (type 2D in the classification of Kragel and Roberts [2]). The case we [3] reported was of this type and importantly did not have anatomic features of an intramural aortic segment or a slitlike orifice.

We consider coronary reimplantation the procedure of choice for most cases of anomalous origin of the coronary artery. We also prefer unroofing of intramural segments with slit ostia, and ostial translocation, if this is possible. In our particular patient, however, this was not an option. The risk of coronary reimplantation was thought to outweigh the benefit because of lack of sufficient tissue at the right coronary ostium, which shared a common ostium with the left main coronary artery. An additional concern was the long-term risk to the left main coronary artery from dissection of the intimately related right coronary artery origin. Finally, there was no intramural component of the right coronary artery, and therefore unroofing was not an alternative. Under these circumstances, the only rational explanation for intermittent coronary insufficiency is coronary compression by the main pulmonary artery. We postulate that moving the pulmonary artery away from the coronary artery effectively relieves this.

Anomalous origin of the right coronary artery comprises an anatomic spectrum and thus is suitable for repair with a variety of surgical options. In general, coronary reimplantation is straightforward in experienced hands. However, we take issue with the contention that it is simpler than pulmonary artery translocation when the anatomic details are similar to those in our patient. Pulmonary artery translocation, a newly described surgical alternative, represents a safer option for achieving excellent results in children with certain forms (type 2D) of complex anomalous right coronary anatomy. Pulmonary artery translocation is easily accomplished on normothermic cardiopulmonary bypass, and aortic cross-clamping and myocardial ischemia are avoided. Furthermore, the coronary arteries themselves are not directly manipulated. In children, this may be more of a critical factor.

References

1. 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;58:828-832.
2. Kragel 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;62:771-777.[Medline]
3. Rodefeld M.D., Culbertson C.B., Rosenfeld H.M., Hanley F.L., Thompson L.D. Pulmonary artery translocation: a surgical option for complex anomalous coronary artery anatomy. Ann Thorac Surg 2001;72:2150-2152.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mark Rodefeld Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Rodefeld, M. Search for Related Content PubMed Articles by Rodefeld, M. Related Collections Congenital - cyanotic