Interactive Cardiovascular and Thoracic Surgery 2:190-192(2003)
© 2003 European Association of Cardio-Thoracic Surgery
Direct coronary reimplantation for anomalous origin of the right coronary from the left sinus of Valsalva
Kojiro Furukawa*,
Masayuki Sakaguchi,
Satoshi Ohtsubo and
Tsuyoshi Itoh
Department of Thoracic and Cardiovascular Surgery, Saga Medical School, 5-1-1 Nabeshima, Saga City 849-8501, Japan
* Corresponding author. Tel.: +81-952-342345; fax: +81-952-34-2061
furukawk{at}post.saga-med.ac.jp
Received September 30, 2002;
received in revised form January 14, 2003;
accepted February 6, 2003
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Abstract
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A 41-year-old man was diagnosed with anomalous origin of the right coronary artery from the left sinus of Valsalva with a slit ostium. Surgery was offered to the patient in view of his young age and the unpredictable natural history of the disease. Direct reimplantation of the right coronary artery to the right sinus was performed under cardiopulmonary bypass. The patient recovered uneventfully. Postoperative coronary angiography showed good patency of the reconstructed artery while exercise thallium scintigraphy showed no ischemic change. Excellent longevity of the directly reimplanted coronary artery can be expected.
Key Words: Reimplantation; Anomalous origin; Right coronary artery; Left sinus
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1. Introduction
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Right coronary arteries that arise from the left sinus with a slit ostium can cause myocardial ischemia, myocardial infarction, or sudden death [1–3]. However, selection of the appropriate surgical treatment remains controversial. Although coronary artery bypass is a simple procedure, this is associated with potential problems including early graft failure and unsatisfactory long-term patency [4,5]. Because reimplantation is technically demanding, few reports of such techniques are available [6–8].
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2. Case report
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This patient was a 41-year-old man whose chief complaint was frequent chest pain. He had been suffering from chest pain since December 2000, and this symptom had been frequent since December 2001. Holter ECG showed an inverted T wave when the patient was symptomatic. Exercise thallium cardiac scintigraphy was negative. Coronary angiography showed an intact left coronary artery, but no coronary artery was found at the right sinus of Valsalva. Instead, the right coronary artery originated from the left sinus, with severe stenosis of the ostium (Fig. 1). Three-dimensional computed tomography clearly revealed that the right coronary artery originated from the left sinus and coursed between the ascending aorta and the pulmonary trunk, before turning to reach its normal location in the right atrioventricular groove. The diagnosis was anomalous origin of the right coronary artery from the left sinus of Valsalva, with a slit ostium. Ischemia was, therefore, caused by the ostial stenosis – not by compression by the aorta and pulmonary trunk. Given the unpredictable natural history of his condition and his young age, the patient was offered surgery.
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Fig. 1 (a) Coronary angiography showed the right coronary artery originating from the left sinus with severe stenosis of the ostia. (b) Postoperative coronary angiography confirmed good patency of the right coronary artery with preservation of the conus branch and no stenosis of the anastomotic site.
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A median sternotomy was performed. Epiaortic echocardiography showed an anomalous right coronary artery that ran anterior to the aortic root, with its origin at the posterior aortic root. It was suggested that the anatomy of the proximal artery was the intramural aortic segment. Cardiopulmonary bypass was established between the ascending aorta and the right atrium. A dissection of about 10 cm in length was performed from the epiaortic origin of the artery to the vicinity of the acute marginal branch. After cardioplegic arrest, the ascending aorta was cross-clamped and opened transversely. The slit ostium of the right coronary artery was confirmed just above the left sinus and at the right side of the left coronary ostium (Fig. 2). Therefore, button coronary reimplantation was impossible in this particular case. The proximal end of the artery was transected outside the aorta and the stump was closed using 6-0 polypropylene continuous suture. The right sinus of Valsalva was confirmed and the aorta was punched out just above the sinus for proximal anastomosis. The artery was proximally tailored in a cobra-head fashion to avoid ostial stenosis. Anastomosis was performed using 7-0 polypropylene continuous suture. Care was taken to prevent ostial stenosis and tight strain of the reimplanted artery. Because of the extensive mobilization, the anastomosis was not technically difficult. The aortotomy was closed using 4-0 polypropylene continuous double-layer suture. Weaning from cardiopulmonary bypass was easily achieved. Aortic cross-clamp and cardiopulmonary bypass times were 41 and 106 min, respectively. (Dissection of the right coronary artery was performed under beating heart condition.) An intraoperative flowmeter showed about 70 ml/min, and a good flow pattern, through the reimplanted artery. The reimplanted right coronary artery had sufficient length and no tension.
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Fig. 2 (a) The slit ostium of the right coronary artery was confirmed just above the left sinus (small arrow). Large arrow: anomalous right coronary artery. (b) Reimplanted right coronary artery. arrow: anastomotic site.
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The postoperative course was uneventful. Exercise thallium scintigraphy showed no ischemic change. Postoperative coronary angiography confirmed good patency of the right coronary artery with preservation of the conus branch and no stenosis of the anastomotic site (Fig. 2). Now, at 7 months postoperation, he remains well and without any ischemic events.
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3. Discussion
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The clinical significance of anomalous origin of the right coronary artery from the left sinus of Valsalva has been controversial. Some have reported that the anomaly is a minor disorder of no clinical significance. However, other authors report that the anomaly is associated with myocardial ischemia and sudden death, particularly in young patients [1–3]. There are no indicators for unfavorable outcome; the natural history of the anomaly is thought to be unpredictable. We believe surgical therapy should be recommended to symptomatic older patients and all young patients with these anomalies. In the present case, in view of his young age and the ischemic change with chest pain corresponding to the Holter electrocardiogram, we elected to offer surgical intervention to the patient.
The choice of surgical procedure has also been controversial. Three surgical approaches have been described in the literature: coronary artery bypass grafting [4,5], coronary unroofing [9,10], and coronary reimplantation [6–8]. The coronary artery bypass is a simple procedure, but is associated with potential problems including early graft failure and long-term loss of patency [4,5]. Also, if bypass procedures are to be employed, the question arises: should the native right coronary artery be ligated? Coronary artery bypass grafting, preferentially with the internal mammary artery, should be reserved for young patients. While the technique of coronary unroofing has been employed [9,10], there are questions regarding reproducibility and feasibility because of anatomical variety in the intramural segment of the right coronary artery. This procedure was not an alternative, in the present case, because the ischemia was caused by the ostial stenosis. The most physiological and ideal operation would consist of reimplantation of the anomalous right coronary artery. However, reimplantation is difficult because the anomalous artery cannot be excised with a Carrel patch, as its course may be initially within the aorta and the ostium is often slit-like [5]. Also, this operation has an increased risk of kinking of the coronary artery [8]. If the segment of the right coronary just apposing the anterior wall of the aorta were to be divided and reanastomosed, the risk of stretch of the artery would have to be considered. It should be possible for the divided artery to be reanastomosed, without tension, using extensive dissection and mobilization of the right coronary artery, as we have described here. Thus, this operation – with a cut at the epiaortic site of the right coronary artery and an anastomosis for the right coronary sinus – is a genuine anatomical correction. Furthermore, excellent longevity of the directly reimplanted coronary artery can be expected.
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Footnotes
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Presented at the 16th Annual Meeting of the European Association for Cardio-thoracic Surgery, Monte Carlo, Monaco, September 22–25, 2002.
doi:10.1016/S1569-9293(03)00032-X
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References
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Abstract
1. Introduction