Surgical Treatment of Anomalous Aortic Origin of Coronary Arteries: The Reimplantation Technique and Its Modifications Thierry Carrel, MD Operative Techniques in Thoracic and Cardiovascular Surgery Volume 21, Issue 3, Pages 178-201 (September 2016) DOI: 10.1053/j.optechstcvs.2017.06.001 Copyright © 2017 Elsevier Inc. Terms and Conditions
Figure 1 Different types of anomalous aortic origin of the coronary arteries: right coronary artery from the left posterior sinus of Valsalva (A); Left main coronary artery from the right anterior sinus of Valsalva (B). Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 178-201DOI: (10.1053/j.optechstcvs.2017.06.001) Copyright © 2017 Elsevier Inc. Terms and Conditions
Figure 1 Different types of anomalous aortic origin of the coronary arteries: right coronary artery from the left posterior sinus of Valsalva (A); Left main coronary artery from the right anterior sinus of Valsalva (B). Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 178-201DOI: (10.1053/j.optechstcvs.2017.06.001) Copyright © 2017 Elsevier Inc. Terms and Conditions
Figure 2 Common and separate ostium in anomalous aortic origin of the coronary arteries: right coronary artery and left main coronary artery from a common ostium (A); small separate and narrowed ostium in a case of anomalous right coronary artery (B). Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 178-201DOI: (10.1053/j.optechstcvs.2017.06.001) Copyright © 2017 Elsevier Inc. Terms and Conditions
Figure 3 Potential mechanisms leading to myocardial ischemia in anomalous aortic origin of coronary arteries: Compression between the great vessels (A); small or stenotic ostium (B); acute take-off angle with potential for kinking at the exit of the aortic wall (C); compression of the intramural segment within the aortic wall (D); and compression of the intramural segment by the commissure of the aortic valve (E). Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 178-201DOI: (10.1053/j.optechstcvs.2017.06.001) Copyright © 2017 Elsevier Inc. Terms and Conditions
Figure 4 Anomalous left coronary artery from the right sinus. Following aortotomy, detailed inspection of the aortic root and identification of the origins of the coronary arteries is performed. The coronary arteries may have either a common or a separate orifice in the same sinus of Valsalva. An intramural course (A) may be found in both conditions and should be examined very carefully to evaluate the length of the intramural portion of the anomalous coronary artery and its relationship to the corresponding commissure of the aortic valve. Extramural course means that the most proximal portion of the anomalous coronary artery runs immediately as epicardial vessel close to the aortic wall (B) or well separated from the aorta (C). Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 178-201DOI: (10.1053/j.optechstcvs.2017.06.001) Copyright © 2017 Elsevier Inc. Terms and Conditions
Figure 5 Anomalous left coronary artery from the right sinus. In patients with a truly extramural type of a left anomalous coronary artery (A), excision of a generous aortic button including the anomalous coronary artery (similar to coronary artery excision performed during aortic root repair [David procedure] or replacement [modified Bentall procedure]) (B) and direct reimplantation into the anatomically appropriate sinus of Valsalva is a good option. Adequate mobilization of the proximal portion of the coronary artery may be necessary to avoid tension or any degree of distortion. Adequate orientation of the button (sometimes a 90-degree rotation is necessary to match the most ideal footpoint of the button together with that of the neo-ostium). The site of button excision is filled with a small piece of xenopericardium (C-E). Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 178-201DOI: (10.1053/j.optechstcvs.2017.06.001) Copyright © 2017 Elsevier Inc. Terms and Conditions
Figure 5 Anomalous left coronary artery from the right sinus. In patients with a truly extramural type of a left anomalous coronary artery (A), excision of a generous aortic button including the anomalous coronary artery (similar to coronary artery excision performed during aortic root repair [David procedure] or replacement [modified Bentall procedure]) (B) and direct reimplantation into the anatomically appropriate sinus of Valsalva is a good option. Adequate mobilization of the proximal portion of the coronary artery may be necessary to avoid tension or any degree of distortion. Adequate orientation of the button (sometimes a 90-degree rotation is necessary to match the most ideal footpoint of the button together with that of the neo-ostium). The site of button excision is filled with a small piece of xenopericardium (C-E). Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 178-201DOI: (10.1053/j.optechstcvs.2017.06.001) Copyright © 2017 Elsevier Inc. Terms and Conditions
Figure 5 Anomalous left coronary artery from the right sinus. In patients with a truly extramural type of a left anomalous coronary artery (A), excision of a generous aortic button including the anomalous coronary artery (similar to coronary artery excision performed during aortic root repair [David procedure] or replacement [modified Bentall procedure]) (B) and direct reimplantation into the anatomically appropriate sinus of Valsalva is a good option. Adequate mobilization of the proximal portion of the coronary artery may be necessary to avoid tension or any degree of distortion. Adequate orientation of the button (sometimes a 90-degree rotation is necessary to match the most ideal footpoint of the button together with that of the neo-ostium). The site of button excision is filled with a small piece of xenopericardium (C-E). Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 178-201DOI: (10.1053/j.optechstcvs.2017.06.001) Copyright © 2017 Elsevier Inc. Terms and Conditions
Figure 6 Anomalous right coronary artery from the left sinus. The direct reimplantation technique for a right coronary artery originating from the left sinus (A) is summarized in the following steps: excision of the aortic button with the coronary artery (B); creation of a neo-ostium in the corresponding sinus using a punch (C); the reimplantation itself using a 6.0 polypropylene running suture and closure of the button procurement site using a small patch of autologous or xenopericardium (D). Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 178-201DOI: (10.1053/j.optechstcvs.2017.06.001) Copyright © 2017 Elsevier Inc. Terms and Conditions
Figure 6 Anomalous right coronary artery from the left sinus. The direct reimplantation technique for a right coronary artery originating from the left sinus (A) is summarized in the following steps: excision of the aortic button with the coronary artery (B); creation of a neo-ostium in the corresponding sinus using a punch (C); the reimplantation itself using a 6.0 polypropylene running suture and closure of the button procurement site using a small patch of autologous or xenopericardium (D). Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 178-201DOI: (10.1053/j.optechstcvs.2017.06.001) Copyright © 2017 Elsevier Inc. Terms and Conditions
Figure 6 Anomalous right coronary artery from the left sinus. The direct reimplantation technique for a right coronary artery originating from the left sinus (A) is summarized in the following steps: excision of the aortic button with the coronary artery (B); creation of a neo-ostium in the corresponding sinus using a punch (C); the reimplantation itself using a 6.0 polypropylene running suture and closure of the button procurement site using a small patch of autologous or xenopericardium (D). Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 178-201DOI: (10.1053/j.optechstcvs.2017.06.001) Copyright © 2017 Elsevier Inc. Terms and Conditions
Figure 6 Anomalous right coronary artery from the left sinus. The direct reimplantation technique for a right coronary artery originating from the left sinus (A) is summarized in the following steps: excision of the aortic button with the coronary artery (B); creation of a neo-ostium in the corresponding sinus using a punch (C); the reimplantation itself using a 6.0 polypropylene running suture and closure of the button procurement site using a small patch of autologous or xenopericardium (D). Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 178-201DOI: (10.1053/j.optechstcvs.2017.06.001) Copyright © 2017 Elsevier Inc. Terms and Conditions
Figure 7 View from outside during the running suture into the punched hole. Closure of the aortotomy has been performed using 4.0 monofilament running suture. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 178-201DOI: (10.1053/j.optechstcvs.2017.06.001) Copyright © 2017 Elsevier Inc. Terms and Conditions
Figure 8 Modified reimplantation of the right coronary artery using an enlargement technique of the ostium and refixation of the aortic valve commissure: because the anomalous coronary artery usually arises from the opposite sinus and is very close to the commissure, detachment of the aortic valve commissure may be necessary to remodel and enlarge the ostium or to excise it with a sufficient button of aortic wall tissue for further reimplantation. The commissure is then resuspended with a 6.0 polypropylene suture, pledgeted with autologous pericardium. Small anomalous right coronary artery within or close to the commissure (A). Detachment of the aortic valve commissure between the left and right aortic cusps and excision of the aortic button (B). Translocation of the right coronary artery to the right (anterior) sinus together with enlargement of the ostium (C). Refixation of the commissure (D). In case of a slit-like ostium, direct reimplantation may be possible only if cranial enlargement using a xenopericardial patch is performed (E). Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 178-201DOI: (10.1053/j.optechstcvs.2017.06.001) Copyright © 2017 Elsevier Inc. Terms and Conditions
Figure 8 Modified reimplantation of the right coronary artery using an enlargement technique of the ostium and refixation of the aortic valve commissure: because the anomalous coronary artery usually arises from the opposite sinus and is very close to the commissure, detachment of the aortic valve commissure may be necessary to remodel and enlarge the ostium or to excise it with a sufficient button of aortic wall tissue for further reimplantation. The commissure is then resuspended with a 6.0 polypropylene suture, pledgeted with autologous pericardium. Small anomalous right coronary artery within or close to the commissure (A). Detachment of the aortic valve commissure between the left and right aortic cusps and excision of the aortic button (B). Translocation of the right coronary artery to the right (anterior) sinus together with enlargement of the ostium (C). Refixation of the commissure (D). In case of a slit-like ostium, direct reimplantation may be possible only if cranial enlargement using a xenopericardial patch is performed (E). Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 178-201DOI: (10.1053/j.optechstcvs.2017.06.001) Copyright © 2017 Elsevier Inc. Terms and Conditions
Figure 9 Modified reimplantation technique after Karl et al8,9; this represents an ideal approach for an LMCA originating from the right sinus (A). The aorta is transected. An incision is made into the ostium of the anomalous coronary artery beginning from the cut edge of the aorta. The incision extends close on the bifurcation of the left main coronary artery. The pericardial patch is sutured into this incision to enlarge the proximal segment of the anomalous coronary and create, thereby, an ostium of 5 mm or more. Thereafter, the ascending aorta is re-anastomosed, incorporating the base of the pericardial patch into the anastomotic suture line (B). This procedure is almost physiological because it allows enlargement of a slit-like ostium, augmentation of the diameter of the proximal coronary segment, and improvement of the acute angulation at the take-off site. In case the anomalous coronary artery runs between the great arteries, the pulmonary artery is transected just under the bifurcation. The incision is continued into the left branch, and thereafter pulmonary translocation (the main pulmonary artery is anastomosed to the left branch, whereas the right pulmonary artery is closed with a pericardial patch to avoid stenosis) helps to resolve compression of the coronary artery between the great vessels. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 178-201DOI: (10.1053/j.optechstcvs.2017.06.001) Copyright © 2017 Elsevier Inc. Terms and Conditions
Figure 9 Modified reimplantation technique after Karl et al8,9; this represents an ideal approach for an LMCA originating from the right sinus (A). The aorta is transected. An incision is made into the ostium of the anomalous coronary artery beginning from the cut edge of the aorta. The incision extends close on the bifurcation of the left main coronary artery. The pericardial patch is sutured into this incision to enlarge the proximal segment of the anomalous coronary and create, thereby, an ostium of 5 mm or more. Thereafter, the ascending aorta is re-anastomosed, incorporating the base of the pericardial patch into the anastomotic suture line (B). This procedure is almost physiological because it allows enlargement of a slit-like ostium, augmentation of the diameter of the proximal coronary segment, and improvement of the acute angulation at the take-off site. In case the anomalous coronary artery runs between the great arteries, the pulmonary artery is transected just under the bifurcation. The incision is continued into the left branch, and thereafter pulmonary translocation (the main pulmonary artery is anastomosed to the left branch, whereas the right pulmonary artery is closed with a pericardial patch to avoid stenosis) helps to resolve compression of the coronary artery between the great vessels. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 178-201DOI: (10.1053/j.optechstcvs.2017.06.001) Copyright © 2017 Elsevier Inc. Terms and Conditions
Figure 10 Modified reimplantation of an anomalous left coronary artery with intramural course between the great vessels. For this special malformation, the technique of Pascal Vouhé, which is a further modification of Karl et al's technique, is useful.10 This technique is specially indicated for an anomalous left coronary artery originating from the right sinus of Valsalva and with an intramural course between the great arteries. In such cases, it is recommended to divide the aorta at the level of the sinotubular junction and the main pulmonary artery just above the pulmonary valve commissures. Both vessels are separated from each other as low as possible, close to the annular plane. The most proximal epicardial course of the left coronary artery is incised in a longitudinal fashion. Then a vertical incision is performed into the left sinus in the direction of the incised left coronary artery (A). Both incisions are joined together and may be approximated at the level where the intramural part of the coronary artery becomes extramural (B). A patch of fresh autologous or xenopericardium is used to enlarge and close the aortocoronary incision and therefore create the neo-ostium in the left sinus. The aortic re-anastomosis is performed, including the top edge of the pericardial patch into the aortic anastomotic suture line (C). Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 178-201DOI: (10.1053/j.optechstcvs.2017.06.001) Copyright © 2017 Elsevier Inc. Terms and Conditions
Figure 10 Modified reimplantation of an anomalous left coronary artery with intramural course between the great vessels. For this special malformation, the technique of Pascal Vouhé, which is a further modification of Karl et al's technique, is useful.10 This technique is specially indicated for an anomalous left coronary artery originating from the right sinus of Valsalva and with an intramural course between the great arteries. In such cases, it is recommended to divide the aorta at the level of the sinotubular junction and the main pulmonary artery just above the pulmonary valve commissures. Both vessels are separated from each other as low as possible, close to the annular plane. The most proximal epicardial course of the left coronary artery is incised in a longitudinal fashion. Then a vertical incision is performed into the left sinus in the direction of the incised left coronary artery (A). Both incisions are joined together and may be approximated at the level where the intramural part of the coronary artery becomes extramural (B). A patch of fresh autologous or xenopericardium is used to enlarge and close the aortocoronary incision and therefore create the neo-ostium in the left sinus. The aortic re-anastomosis is performed, including the top edge of the pericardial patch into the aortic anastomotic suture line (C). Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 178-201DOI: (10.1053/j.optechstcvs.2017.06.001) Copyright © 2017 Elsevier Inc. Terms and Conditions
Figure 10 Modified reimplantation of an anomalous left coronary artery with intramural course between the great vessels. For this special malformation, the technique of Pascal Vouhé, which is a further modification of Karl et al's technique, is useful.10 This technique is specially indicated for an anomalous left coronary artery originating from the right sinus of Valsalva and with an intramural course between the great arteries. In such cases, it is recommended to divide the aorta at the level of the sinotubular junction and the main pulmonary artery just above the pulmonary valve commissures. Both vessels are separated from each other as low as possible, close to the annular plane. The most proximal epicardial course of the left coronary artery is incised in a longitudinal fashion. Then a vertical incision is performed into the left sinus in the direction of the incised left coronary artery (A). Both incisions are joined together and may be approximated at the level where the intramural part of the coronary artery becomes extramural (B). A patch of fresh autologous or xenopericardium is used to enlarge and close the aortocoronary incision and therefore create the neo-ostium in the left sinus. The aortic re-anastomosis is performed, including the top edge of the pericardial patch into the aortic anastomotic suture line (C). Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 178-201DOI: (10.1053/j.optechstcvs.2017.06.001) Copyright © 2017 Elsevier Inc. Terms and Conditions