Complete unroofing of the intramural coronary artery for anomalous aortic origin of a coronary artery: The role of commissural resuspension?

Abstract

Objectives: Although surgical repair of an anomalous aortic origin of the coronary artery has low operative mortality, longer-term risk of ischemia and aortic regurgitation remains concerning. We routinely perform aortic commissure resuspension after unroofing and sought to evaluate the outcomes with regard to aortic valve competence, symptoms, and signs of ischemia with this approach. Methods: Twenty-six consecutive patients who received the unroofing procedure for anomalous aortic origin of the coronary artery (10 left; 16 right) between 2004 and 2016 were reviewed. In addition to complete unroofing of the intramural coronary, patients early in the cohort (n ¼ 9) received unroofing only, and aortic commissural resuspension was performed routinely in the subsequent patients (n ¼ 17). Outcomes between commissural resuspension versus no commissural resuspension were compared. The occurrence of mild and greater aortic regurgitation was assessed using a time-to-event analysis after varying lengths of time. Commissural resuspension was considered as the predictor, and the groups were compared using a log-rank test. Results: There was no operative mortality. One patient in the no commissural resuspension group died 10 years later of prosthetic aortic valve endocarditis (aortic valve replacement 7 years after unroofing). The follow-up duration was 6.9 years (4.9-9.1) and 3.7 years (2.1-4.3) in the no commissural resuspension and commissural resuspension groups, respectively (P ¼ .001). Available postoperative exercise stress test data (n ¼ 14) revealed that 50% had an endurance level at the 25th percentile or greater for age. After a median follow-up of 1.9 years (3 months to 10.6 years), no patient in the commissural resuspension group had aortic regurgitation, whereas 6 of 9 patients (67%) in the no commissural resuspension group had stable but mild or greater aortic regurgitation. Time-to-event analysis with the primary event of occurrence of mild or greater aortic regurgitation showed significantly higher freedom from the occurrence of aortic regurgitation in the commissural resuspension group (P ¼ .035). Conclusions: Surgical repair of an anomalous aortic origin of the coronary artery can be performed with excellent early and midterm outcomes. Routine commissural resuspension of the aortic valve may lead to a lower rate of aortic valve regurgitation without increasing the risk of ischemia.

Surgery for Anomalous Aortic Origin of Coronary Arteries: Technical Safeguards and Pitfalls

“…Last, the detached commissure is suspended above the unroofed intramural segment with pledgeted suture(s) ( Figure 5A ). Commissural resuspension is a technique that may lower the rate of aortic valve regurgitation and does not add any proven additional risk to the procedure ( 29 ). Alternatively, when the intramural coronary segment courses below the sino-tubular junction, a “neo-ostium” can be created in the correct sinus, at the point where the coronary artery emerges from the aortic wall ( Figure 5B ).…”

“…Also, when detaching and then resuspending the commissure, the aortic valve regurgitation remains at risk. Last, the recent recognition of the intercoronary pillar is of some interest, a thickening of the aortic wall above the commissure, as a possible contributor to both pathophysiology of AAOCA and aortic valve support ( 29 ). The intercoronary pillar is the aortic wall segment above the intercoronary commissure, usually thicker than the remaining wall.…”

“…While the unroofing of a long intramural segment can effectively move the ostium into the correct sinus and away from the intercoronary pillar when the intramural segment is short, the simple unroofing may be ineffective since the anomalous coronary artery may be left close to the pillar, and at risk for potential compression. Some authors have reported ( 29 ) that the latter can occur after unroofing and suggest alternative surgical techniques in such cases, i.e., coronary translocation. Furthermore, this potential negative outcome may be even more probable when the coronary commissure needs to be resuspended after unroofing of a short segment since this can replace the inter- coronary pillar close to the new coronary ostium.…”

Current surgical management of anomalous aortic origin of a coronary artery

“…Resuspension should be performed regardless of whether or not aortic valve commissural detachment was performed, as it is crucial to securely resuspend the commissure to prevent late aortic insufficiency. Yerebakan and colleagues 8 recently reported that a modified unroofing technique with routine commissural resuspension was associated with a lower rate of aortic regurgitation (AR).…”

Anomalous aortic origin of the coronary arteries in a 12-year-old male: a case report

“…Studies have shown that the right coronary artery is more involved in the incidence of AAOCA than the left coronary artery [3]. However, AAOCA involving the left coronary artery carries a higher risk [4].…”