Coronary unroofing does not fits all anomalous aortic origin of coronary arteries

Abstract

Introduction: Anomalous aortic origin of coronary artery (AAOCA) is the second leading cause of sudden cardiac death in children and young adults. Intramuralinterarterial course is the most frequent anatomic variation and coronary unroofing is widest adopted for surgical management. Symptoms recurrence is described regardless of the technique used. This study aims to describe how an anatomic patient-centered approach aimed to restore a normal coronary artery take-off is associated with symptoms resolution. Methods: From 2008 to 2021, 25 patients were operated on for an AAOCA at a median age of 20 years. Nineteen patients had a right AAOCA and six had left AAOCA. Intramural course was present in 18 patients. Seventy-six percent were symptomatic. No episodes of aborted sudden cardiac death before surgery was described in the population. Surgical technique used were coronary unroofing in 18 patients, coronary neo-ostioplasty in 3, coronary Reimplantation in 3, and main pulmonary artery re-location in 1.Results: No hospital mortality or reoperation was observed in our experience as well as major complications related to surgery. Mean hospital length of stay was 8.5 days.None of patients reported symptoms recurrence at follow-up. Young athletes returned to play competitive sport. Postoperative computed tomography scan evaluation showed a general improvement of the take-off angle.Conclusions: AAOCA requires a patient anatomic-based surgical management. There is not a single surgical technique that can fits all anatomic subtype of AAOCA.Surgical techniques may be selected on the base of the preoperative images and intraoperative findings. In our experience, this policy is associated with no symptoms recurrence. | INTRODUCTIONAnomalous aortic origin of coronary arteries (AAOCA) is a noninfrequent congenital, anatomic heart anomaly whose recognition in the population is dramatically heightened in the last years. [1][2][3][4] The association with sudden cardiac death in athletes has improved the medical awareness of this malformation leading to an increase in cardiologic investigations, especially before competitive sport practice. 5 Several studies have attempted to quantify this value, with estimates ranging between 0.1% and 1% in both the adult and

Case Report: Neo-ostium creation with saphenous vein in a patient with anomalous origin of the right coronary artery

“…Unroofing techniques may cause atherosclerosis and scarring in the long term due to significant manipulation of the coronary artery (14). In a study conducted by Arcieri et al it was suggested that coronary unroofing is not a technique suitable for all anatomic subtypes of anomalous origin of coronary arteries and that the selection of a surgical technique must be done according to a specific patient anatomy-based approach (15). In our case, the RCA had an interarterial and intramural course with a stenotic ostium.…”

Recommendations for cardiovascular magnetic resonance and computed tomography in congenital heart disease: a consensus paper from the CMR/CCT Working Group of the Italian Society of Pediatric Cardiology and the Italian College of Cardiac Radiology endorsed by the Italian Society of Medical and Interventional Radiology (Part II)

“…Echocardiography can usually provide this information but may be limited in older patients and prone to false negatives. 55,56 Coronary imaging is especially indicated in repaired CHD involving coronary reimplantation as TGA treated by arterial switch operation. Major complications in this setting include coronary stenosis at anastomotic sites, neo-aortic dilation, neo-pulmonary or branch pulmonary artery stenosis, and valvular or ventricular dysfunction.…”

“…In addition, neither echocardiography nor CMR can consistently evaluate distal coronary anatomy. 55,56,[58][59][60] CMR may also be an option and can provide important information on additional findings, including global and regional function, perfusion, and viability. Because late coronary complications are reported to be very low, routine screening of coronary arteries is still questionable in TGA patients post atrial switch; therefore, CMR is generally indicated to assess pulmonary trunk and branches, ventricular volumes, FE, aortic root dilatation, and regurgitation and is an alternative technique to assess myocardial perfusion and possibly coronary artery compromise, when clinically indicated.…”

“…In most congenital anomalies, only visualization of the origin and proximal course of the coronary arteries is required. Echocardiography can usually provide this information but may be limited in older patients and prone to false negatives 55,56 …”

“…CMR is more helpful than echocardiography to describe CCA but features like intramural courses cannot be reliably determined by CMR. In addition, neither echocardiography nor CMR can consistently evaluate distal coronary anatomy 55,56,58–60 …”