Surgical management of coronary artery arising from the wrong coronary sinus, using standard and novel approaches

Gulati, Rajeev; Reddy, Vadiyala Mohan; Culbertson, Casey; Helton, Gregory; Suleman, Sam; Reinhartz, Olaf; Silverman, Norman; Hanley, Frank L.

doi:10.1016/j.jtcvs.2007.02.051

« Previous Next »The Journal of Thoracic and Cardiovascular Surgery
Volume 134, Issue 5 , Pages 1171-1178.e5, November 2007

Surgical management of coronary artery arising from the wrong coronary sinus, using standard and novel approaches

Rajeev Gulati, MD
- Department of Pediatric Cardiac Surgery, Stanford University Medical Center, Stanford, Calif
- Address for reprints: Rajeev Gulati, MD, Pomona Valley Hospital, 160 East Artesia Street, Suite 355, Pomona, CA 91767.
Vadiyala Mohan Reddy, MD
- Department of Pediatric Cardiac Surgery, Stanford University Medical Center, Stanford, Calif
Casey Culbertson, MD
- Department of Pediatric Cardiology, Children’s Hospital Oakland, Oakland, Calif
Gregory Helton, MD
- Department of Pediatric Cardiology, Children’s Hospital Oakland, Oakland, Calif
Sam Suleman, MD
- Department of Pediatric Cardiac Surgery, Stanford University Medical Center, Stanford, Calif
Olaf Reinhartz, MD
- Department of Pediatric Cardiac Surgery, Stanford University Medical Center, Stanford, Calif
Norman Silverman, MD
- Department of Pediatric Cardiology, Stanford University Medical Center, Stanford, Calif.
Frank L. Hanley, MD
- Department of Pediatric Cardiac Surgery, Stanford University Medical Center, Stanford, Calif

Received 22 June 2006; received in revised form 29 January 2007; accepted 14 February 2007. published online 05 October 2007.

Objectives

Patients with a coronary artery arising from the wrong sinus are susceptible to ischemia and sudden death. Risk is higher when the artery courses interarterially—between the pulmonary artery and aorta—has an intramural course, or has an abnormal orifice. In single coronary ostium without intramural course, unroofing and coronary reimplantation are inappropriate, and coronary artery bypass grafting is suboptimal. For this variant, we have devised pulmonary artery translocation.

Methods

A retrospective review of 18 patients undergoing repair between January 1999 and March 2005 was performed. Mean age was 8.1 years (range 6 weeks–16 years). All anomalous arteries coursed interarterially. Ten patients had a right coronary artery from the left coronary sinus; 8 had a left coronary artery from the right sinus. Eleven had an intramural course, and 4 had a single coronary ostium without an intramural course. Ten (56%) patients had symptoms: chest pain (9/10), syncope (3/10), or dyspnea (2/10). Repair was implemented by unroofing (n = 11), reimplantation (n = 3), or pulmonary artery translocation (1 lateral, 3 anterior). All patients were followed up clinically and echocardiographically.

Results

At a mean of 2.2 years (2 weeks–5 years), there was no mortality. Symptoms improved and function remained normal in all but 1 patient. He had sustained multiple infarcts in the anomalous artery’s distribution and required transplantation despite repair.

Conclusions

Repair is indicated in all patients with coronary insufficiency and in asymptomatic patients with high-risk morphologic abnormalities. We recommend unroofing when an intramural component (or slit-like orifice) is present, reimplantation for separate ostia without an intramural course, and pulmonary artery translocation for single ostium without an intramural course. Coronary artery bypass grafting is thus avoided.

CTSNet classification: 18, 20, 23, 34

Abbreviations and Acronyms: LCA, left coronary artery, LCS, left coronary sinus, PA, pulmonary artery, RCA, right coronary artery, RCS, right coronary sinus