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Modified Re-implantation Technique For Anomalous Origin Of Right Coronary Artery From Left Sinus With Short Intramural Course
Hani K. Najm, MD, MSc1, Samantha Xu, BA, MPH2, Lin Chen, BA2, Munir Ahmad, MD1, Joanna Ghobrial, MD, MSc1, Gosta Pettersson, MD, PhD1, Tara Karamlou, MD, MSc1.
1Division of Pediatric Cardiac Surgery and the Heart and Vascular Institute, The Cleveland Clinic, Cleveland, OH, USA, 2Case Western Reserve University School of Medicine, Cleveland, OH, USA.

Objectives: Coronary unroofing of the intramural segment is advocated by many, but patients with an inter-arterial course but short intramural segment may derive less benefit from this approach.Methods: We describe a versatile modification of this technique in two patients with intra-arterial course of anomalous origin of right coronary artery (AAORCA) and short intramural course. Results:Case 1:17-year old male had cardiac arrest. CTA confirmed AAORCA with inter-arterial segment, and a short intramural segment 0.6cm in length. Cardiac catheterization demonstrated left anterior descending myocardial bridging, dominant AAORCA with instantaneous wave-free ratio (iFR) of 0.84 with dobutamine, positive for stress ischemia. Patient was discharged with no complications on POD#5. Case 2:63-year old male with exertional chest pain. CTA coronary demonstrated AAORCA from left sinus with intra-arterial course. Stress/rest nuclear myocardial SPECT imaging with exercise showed decreased uptake in inferoseptal segment with reperfusion at rest. Dobutamine stress test showed moderate (10-20%) ischemia in the territory of RCA. Patient was discharged on POD#6 without complications . Post-operative CTA for both cases showed excellent results. Attached video demonstrates the technique utilized for both patients. Conclusions:Modified re-implantation technique for AAOCA is suitable for patients across the age spectrum, with inter-arterial course without short intramural segment. Configuration of the aortocoronary
anastomosis using a posterior spatulated approach, similar to coronary revascularization, provides favorable anatomic lie and should reduce angulation or kinking.


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