Ann Thorac Surg 2009;87:1948-1949. doi:10.1016/j.athoracsur.2008.10.052
© 2009 The Society of Thoracic Surgeons
Case Reports
Intramural Left Main Coronary Artery Unexpectedly Encountered During Aortic Root Replacement
Basar Sareyyupoglu, MDa,
Harold M. Burkhart, MDa,*,
Joseph A. Dearani, MDa,
Heidi M. Connolly, MDb
a Department of Cardiothoracic Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
b Division of Cardiovascular Diseases, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
Accepted for publication October 14, 2008.
* Address correspondence to Dr Burkhart, Mayo Clinic, Department of Cardiothoracic Surgery, Joseph 5-200, 200 First Street SW, Rochester, MN 55905 (Email: burkhart.harold{at}mayo.edu).
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Abstract
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We present an intramural left main coronary artery, unexpectedly encountered during aortic root replacement in a truncus arteriosus patient. Given the severely limited orifice, we opted to unroof the intramural portion of the left main coronary artery prior to implantation as a button. Until now there have been no reports in the literature describing unroofing an intramural coronary artery prior to reimplantation in an aortic root replacement operation.
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Introduction
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Coronary artery anomalies are known to be associated with truncus arteriosus [1]. Coronary artery unroofing or neo-ostium creations are known procedures to relieve compromised flow in the intramural coursed coronary artery [2, 3]. We describe management of an intramural left main coronary artery diagnosed intraoperatively during aortic root repair.
A 46-year-old woman, with a history of truncus arteriosus repair and right ventricular outflow tract reconstruction at 8 years old, subsequent aortic valve replacement, right ventricular-to-pulmonary artery conduit replacement, and tricuspid annuloplasty at 27 years old, presented for congenital re-evaluation. Work up revealed a 6-cm ascending aorta, severe pulmonary valve regurgitation, severe tricuspid valve regurgitation, and moderate–severe right ventricular enlargement. She was scheduled for third-time sternotomy, aortic root replacement, including ascending aorta, pulmonary valve replacement, and tricuspid valve repair. Of note, at the time of preoperative angiogram she had inadequate left main coronary artery imaging due to failed catheterization of her left coronary ostium, despite aortic root injection. In the operating room, cardiopulmonary bypass was established by using the femoral artery, femoral vein, and superior vena cava cannulation. During preparation of the coronary buttons for subsequent implantation with root replacement, a tight, slit-like left main coronary artery ostium in close proximity to the left coronary–noncoronary commissure was noted. Given the severely limited orifice, we opted to unroof the intramural portion of the left coronary artery. In addition to providing better flow, this maneuver would allow complete visualization of the borders of the left main coronary artery, as it exists in the aortic wall, and to aid in the safe formation and implantation of the button. A 1-cm longitudinal incision was performed over a 2-mm intracoronary probe to obtain larger coronary orifice. Interrupted 6-0 Prolene sutures (Ethicon, Somerville, NJ) were used to stabilize the intima of the neo-coronary button (Fig 1). The remainder of the operation was uneventful and the patient came off cardiopulmonary bypass without difficulty. Post-bypass transesophageal echocardiogram showed excellent flow in the left main coronary artery. The patient was discharged home on postoperative day 7.
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Comment
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Coronary arteries with an intramural component that arise from the wrong coronary sinus are at risk for acute coronary syndromes and sudden death [2]. Coronary artery unroofing with neo-ostium creation is a well-described procedure for relieving compromised flow in intramural coursing coronary arteries [2, 3]. The presence of a slit-like coronary orifice is believed to contribute to the risk of an acute coronary event. Possible mechanisms include [4]: (1) the acute angulation of the coronary takeoff that may get worse or become kinked during exertion; (2) the ostial ridge that may function as a valve-like mechanism and restrict flow during exertion; and (3) the slit-like orifice that may become compressed during hypertension, or during exertion periods, secondary to aortic root dilation and increased wall tension.
Coronary artery reimplantation is a well-known technique used in aortic root replacement procedures. Until now there have been no reports in the literature describing unroofing an intramural coronary artery prior to reimplantation in an aortic root replacement operation. Unroofing the coronary artery provides better visualization of borders of the coronary ostium, which, in turn, should prevent coronary transection during button formation. In addition, coronary hemodynamics will improve by providing unobstructed flow at the end of a prolonged cardiac procedure.
Compression of an anomalous intramural left main coronary artery after prosthetic aortic valve implantation has been reported [5]. It has been proposed that better positioning or undersizing prosthetic valves in association with anomalous and intramural coronary arteries may help to avoid coronary ostial blood flow compromise [5]. We would advocate similar precautions and adding unroofing to the procedure to prevent these complications.
In summary, the presence of an anomalous, intramural coronary artery with a slit-like ostium encountered during a complex aortic root replacement presents a surgical challenge that could result in a disasterous outcome. We would advocate that unroofing the intramural portion of the coronary artery prior to button formation and reimplantion is the optimal solution to this challenging situation.
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References
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- Lenox CC, Debich DE, Zuberbuhler JR. The role of coronary artery abnormalities in the prognosis of truncus arteriosus J Thorac Cardiovasc Surg 1992;104:1728-1742.[Abstract]
- Gulati R, Reddy VM, Culbertson C, et al. Surgical management of coronary artery arising from the wrong coronary sinus, using standard and novel approaches J Thorac Cardiovasc Surg 2007;134:1171-1178.[Abstract/Free Full Text]
- Romp RL, Herlong JR, Landolfo CK, et al. Outcome of unroofing procedure for repair of anomalous aortic origin of left or right coronary artery Ann Thorac Surg 2003;76:589-595discussion 595–6.[Abstract/Free Full Text]
- García-Rinaldi R, Sosa J, Olmeda S, Cruz H, Carballido J, Quintana C. Surgical treatment of right coronary arteries with anomalous origin and slit ostium Ann Thorac Surg 2004;77:1525-1529.[Abstract/Free Full Text]
- Morimoto N, Okita Y, Okada K, Yamashita T, Matsumori M. Aortic valve replacement for a case of anomalous origin of the left coronary artery from posterior sinus of Valsalva with intramural aortic course J Thorac Cardiovasc Surg 2005;130:1713-1714.[Free Full Text]
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Abstract
Introduction
