Repair Of Anomalous Aortic Origin Of A Coronary Artery: How I Do It
Carlos M. Mery.
Dell Medical School at The University of Texas at Austin / Dell Children's Medical Center, Austin, TX, USA.
Many surgical techniques have been described for AAOCA. Since the specific mechanisms of ischemia are unclear, all potential anatomical culprits should be addressed. Surgical unroofing is useful when there is a long intramural segment above the aortic valve. If the intramural segment is not long enough, unroofing will fail to place the ostium in the correct sinus and keep the coronary at risk of compression by the intercoronary pillar (Figure). Coronary reimplantation is a better technique in this setting. This video illustrates technical tricks for unroofing and reimplantation, and how to decide when one technique is a better alternative than the other. A 15-year-old female presented with episodes of chest tightness and lightheadedness. Workup revealed an anomalous right coronary from the left sinus with a 6 mm intramural segment and evidence of ischemia. Aortobicaval cannulation was performed and the right coronary artery dissected. After aortotomy, a transmural stitch was placed to assess the direction and length of intramurality. An unroofing was performed but after unroofing, the ostium still arose very close to the intercoronary pillar and at risk for compression. The decision was made to perform a coronary reimplantation instead. The coronary artery was transected as it arose from the aorta, the stump closed, and the coronary reimplanted into the correct sinus. A CTA showed an adequate result. 
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