Repair of Anomalous Right Coronary Artery From the Pulmonary Artery Using the Modified Trapdoor Technique

Abstract

Background: Anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA) is rare. Unique anatomical characteristics observed include tethering secondary to the extensive collateral vessels, severe native coronary tortuosity, and massive dilation of the coronary arteries. This requires specific technical consideration to ensure safe translocation. Methods: A single-center retrospective review of six patients with ARCAPA was performed. Echocardiographic and computerized tomography scan data were analyzed for anatomical and functional cardiac characteristics. Operative techniques were analyzed, which reflected an evolution toward a modified-trapdoor technique. Results: Five children presented with asymptomatic murmurs and one adult patient with unstable angina. All patients underwent successful surgical correction. The modified trapdoor technique provided the most ideal geometry for coronary transfer secondary to its anatomical characteristics. Two patients had coronary button transfers above the sinotubular junction using vertical stab incisions, one had the button implanted after excising part of the aortic wall, and last three patients had modified trapdoor incisions. Mean cardiopulmonary bypass and cross-clamp times were 170 + 27 minutes and 99.5 + 29 minutes respectively. The average hospital stay was five days and there were no mortalities. Conclusions: Anomalous right coronary from the pulmonary artery's unique anatomical characteristics require a coronary transfer technique different from that performed in aortic root replacement. In some respects, our modified technique resembles coronary transfers used in difficult arterial switch operations. The use of a modified trapdoor incision simplifies coronary transfer and may minimize coronary kinking and subsequent complications related to coronary transfer.

Anomalous Right Coronary Artery Originating From the Pulmonary Artery (ARCAPA): A Rare Presentation in the Fifth Decade

“…Both direct reimplantation and the use of a modified trapdoor technique have been described. 3 In adults, the reimplantation technique may be more challenging due to friability and potential calcification of the coronary artery as well as reduced elasticity compromising mobility of the vessel, which is essential to avoid kinking on reimplantation. 4 However, we believe reimplanting the coronary artery does have the benefits of reestablishing native systemic coronary artery blood flow allowing myocardial perfusion with oxygenated blood and mitigating the potential for thrombosis with low-pressure flow through the dilated coronary artery.…”