Ann Thorac Surg 2003;76:1287-1289
© 2003 The Society of Thoracic Surgeons
Case report
Reimplantation of anomalous right coronary artery arising from the pulmonary trunk leading to normal coronary flow reserve late after surgery
Josef Veselka, MD, PhDa*,
Petr Widimský, MD, DScb,
Josef Kautzner, MD, PhDc
a Division of Cardiac Surgery, Cardiology Section, University Hospital Motol, Prague, Czech Republic
b Department of Cardiology, Cardiac Center, University Hospital Královské Vinohrady, Prague, Czech Republic
c Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
Accepted for publication March 17, 2003.
* Address reprint requests to Dr Veselka, Division of Cardiac Surgery, Cardiology Section, University Hospital Motol, V úvalu 84, Prague 5, 150 00, Czech Republic
e-mail: veselka.josef{at}seznam.cz
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Abstract
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We report a case of successful reimplantation of the right coronary artery from the pulmonary trunk into the aorta with a 10-year follow-up. The finding of a normal coronary flow reserve late after surgery suggests that direct reimplantation of the right coronary artery into the aorta is the preferable surgical technique.
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Introduction
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Anomalous origin of the right coronary artery (RCA) from the pulmonary artery is a rare coronary anomaly. Whereas patients with anomalous pulmonary origin of the left coronary artery present with signs of left ventricular ischemia and congestive heart failure usually in infancy, those with anomalous origin of the RCA remain usually asymptomatic until adulthood. However even patients with the latter anomaly are subject to myocardial ischemia due to the coronary steal phenomenon and an adverse outcome has been described repeatedly in some of them [1, 2]. Hence surgical treatment is recommended whenever this anomaly is recognized.
Since there is ongoing discussion regarding the optimal method of surgical treatment we report a 10-year follow-up of a patient successfully treated by reimplantation of the RCA from the pulmonary trunk into the aorta. Furthermore it is not known whether corrective surgery is able to restore not only normal anatomy but also normal coronary physiology. Thus we measured the coronary flow reserve 10 years postoperatively.
A 36-year-woman with a history of precordial systolic murmur was evaluated because of angina pectoris on maximal exertion. Diagnosis of anomalous origin of the RCA from the pulmonary trunk was established both by coronary angiography (Fig 1)
and echocardiography [3]. Surgical reimplantation of the RCA into the anterior wall of the ascending aorta was subsequently performed. Two months postoperatively, exercise myocardial scintigraphy detected a reversible perfusion defect in the anterolateral and septal region. Repeated coronary angiography revealed persistent dilatation of the RCA with a remarkably slow flow. The left coronary artery was of a normal appearance. Because the results of these tests suggested small vessel disease the patient was started on a regimen of calcium channel blocker (verapamil) therapy.
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Fig 1. The coronary angiogram (right anterior oblique view) showing the left coronary artery before operation. The anomalous right coronary artery originated from the pulmonary trunk is filled from the left coronary artery by numerous collateral vessels.
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After 10 years of uneventful clinical follow-up, exercise single-photon emission computed tomographic (SPECT) myocardial perfusion imaging with 99mTc-sestamibi revealed a small, partially reversible perfusion defect in the anteroseptal region. Left ventricular function assessed by transthoracic echocardiography was normal. Coronary angiography demonstrated a markedly dilated proximal RCA with a normal flow and a rapid filling of the coronary sinus (Fig 2).
The left coronary artery appeared normal (Fig 3).
Coronary flow reserve was measured in both coronary arteries after the intracoronary injection of 10 mg of papaverine. Coronary flow reserve was entirely normal (4.6, with average peak velocity 37 cm/s) for the RCA and borderline (2.0, with average peak velocity 40 cm/s) for the left coronary artery. The patient remains asymptomatic 10 years after the operation.
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Fig 2. The coronary angiogram (right anterior oblique view) showing the right coronary artery at follow-up.
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Comment
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Patients with the anomalous origin of the RCA from the pulmonary artery have numerous collateral vessels directing the blood flow from the left coronary artery through the RCA retrogradely into the pulmonary trunk. Such reverted flow leads to left-to-right shunt of a borderline hemodynamic significance and results in the coronary steal phenomenon with potential consequences of myocardial ischemia. As this anomaly is known to be associated with increased risk of myocardial infarction and sudden death without any preceding symptoms, prophylactic surgical therapy is commonly recommended [1, 2]. Three different surgical procedures have been previously advocated [1]. First, the RCA ligation at its origin from the pulmonary trunk has been proposed to eliminate coronary steal. However the long-term results with this approach appear to be unpredictable and the patients are subject to unknown long-term effects of a single coronary artery status. Conversely simple ligation of the RCA is well tolerated [4], similar to ligation of the left coronary artery originating from the pulmonary trunk. Second, the ligation of the RCA at its origin plus subsequent aortocoronary saphenous vein bypass graft to its distal portion has been suggested to restore blood supply through both coronary arteries. Unfortunately the long-term patency of the saphenous graft may be limited and the procedure is technically more demanding. Third, direct reimplantation of the RCA from the pulmonary artery into the anterior wall of the ascending aorta has been recommended to establish a double coronary artery system. This procedure is technically feasible as the RCA is usually long enough and including a cuff of the pulmonary artery permits creation of a large anastomosis. In addition this type of surgery does not necessarily require cardiopulmonary bypass and long-term patency of direct arterial anastomosis is likely to be better than that of the venous bypass. Not surprisingly this procedure has many proponents. However the superiority of direct RCA reimplantation into the aorta has not been objectively documented yet. Because this anomaly is very rare and the number of detailed case reports is limited, the above concept is based solely on the assumption of physiologic restoration of the coronary artery tree.
In one of our previous reports we hypothesized that long-term hyperkinetic circulation associated with anomalous origin of the RCA from the pulmonary artery might be a possible explanation for the postoperative impairment of flow in restored RCA, probably due to persistent small vessel disease [3]. However this observation was based on short-term postoperative follow-up. In this case we report the results of coronary flow reserve measurement at 10 years after such corrective surgery. The normal coronary flow reserve value in the reimplanted RCA obtained in our patient suggests the physiologic restoration of coronary blood supply and together with the normal appearance of coronary arteriogram seems to confirm the validity of the double coronary artery concept.
Despite the apparent success of RCA reimplantation into the aorta the presence of a small anteroseptal ischemic region should be noted in our patient. In this respect T
ma and colleagues [5] found a reversible perfusion defect within the inferior wall 8 years after the same type of surgical correction of this anomaly. Similarly Lambert and associates [6] described both transient and persistent ischemic defects in the anteroseptal and anterolateral segments of the left ventricle of patients after corrective operation of the left coronary artery originating from the pulmonary artery during the midterm follow-up. The reason for such detectable myocardial ischemia in the above cases remains unclear. It may reflect a small scar as a result of previous prolonged ischemia or it may be compatible with a minor degree of persisting impairment of the microvasculature. That might be supported by the borderline coronary flow reserve value (2.0) in the left coronary artery found in this case. On the contrary other case reports documented complete disappearance of myocardial ischemia after the corrective surgery [1].
In conclusion the detailed analysis of our case suggests that surgical reimplantation of the anomalous RCA from the pulmonary trunk into the aorta appears to be the preferred therapy leading to coronary flow reserve normalization in both coronary arteries over a long-term period.
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References
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- Bregman D., Brennan J.F., Singer A., et al. Anomalous origin of the right coronary artery from the pulmonary artery. J Thorac Cardiovasc Surg 1976;72:626-630.[Abstract]
- Lerberg D.B., Ogden J.A., Zuberbuhler J.R., Bahnson H.T. Anomalous origin of the right coronary artery from the pulmonary artery. Ann Thorac Surg 1979;27:87-94.[Abstract]
- Kautzner J., Veselka J., Rohac J. Anomalous origin of the right coronary artery from the pulmonary trunk: is surgical reimplantation into the aorta a method of choice?. Clin Cardiol 1996;19:257-259.[Medline]
- Rowe G.G., Young W.P. Anomalous origin of the coronary arteries with special reference to surgical treatment. J Thorac Cardiovasc Surg 1960;39:777-780.
- Tma S., Hu
ín B., Reich O., Vo
í
ková M., Radvanský J. Abnormal origin of the right coronary artery from the pulmonary artery. 
s Pediat 1990;45:543-545.
- Lambert V., Touchot A., Losay J., et al. Midterm results after surgical repair of the anomalous origin of the coronary artery. Circulation 1996;94(Suppl):1138-1143.
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Abstract
Introduction
