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

Anterior pulmonary artery (PA) translocation. A, Anomalous left coronary artery from the right coronary sinus (RCS), with single origin and normal proximal course. B, Both branch PAs are fully mobilized and right branch PA is transected and moved anterior to the aorta. C, The right PA is reattached and a pericardial patch is added, as necessary. This moves the main PA both anteriorly and leftward, relieving compression on the interarterial portion of the anomalous artery.

Morphology-based surgical management protocol. PA, Pulmonary artery; RCA, right coronary artery; RCS, right coronary sinus; LCA, left coronary artery; LCS, left coronary sinus.

High-risk anomalous coronary artery patterns. PA, Pulmonary artery; P, posterior “noncoronary” sinus of Valsalva; L, left sinus of Valsalva; R, right sinus of Valsalva. A, Anomalous right coronary artery (RCA) with separate ostium, arising from left coronary sinus (LCS), coursing interarterially, between the PA and aorta, without intramural course (n = 2 in this series). B, Anomalous RCA with single ostium (shared with left coronary artery [LCA]), arising from LCS, and coursing interarterially between the PA and aorta, without intramural course (n = 1). C, Anomalous LCA with separate ostium, arising from right coronary sinus (RCS), coursing interarterially between the PA and aorta, without intramural course (n = 0). D, Anomalous LCA with single ostium (shared with RCA), arising from right coronary sinus (RCS), and coursing interarterially between the PA and aorta, without intramural course (n = 2). E, Anomalous LCA with single ostium (shared with RCA), arising from the RCS and coursing interarterially and intramuscularly between the PA and aorta, without intramural course (n = 1) RVOT, Right ventricular outflow tract. F, Anomalous LCA with separate ostium, arising from the RCS, coursing interarterially and between the PA and aorta, with intramural course (N = 4). G, Anomalous RCA with separate ostium, arising from the, coursing interarterially between the PA and aorta, with intramural course (n = 7). Although not illustrated here, anomalous RCA with common ostium (shared with LCA) arising from the LCS, coursing interarterially between the PA and aorta, with intramural course, may occur (n = 1).

Normal and low-risk anomalous coronary artery. B through D are considered low risk if there is no abnormality of the coronary origin. A, Normal coronary arteries. B, Anomalous LCA with separate ostium, arising from RCS, coursing posteriorly, around aorta. C, Anomalous LCA with separate ostium, arising from posterior (noncoronary) sinus, coursing posteriorly, around aorta. D, Anomalous LCA with separate ostium, arising from RCS, coursing anteriorly, around PA. For abbreviations, see .

Unroofing. Patient with anomalous LCA from LCS, with intramural course. A, The intramural course is opened up over its full length, along the dotted line. B, The edges are trimmed. If necessary, the cut edges are reinforced with fine suture and the aortic valve commissure is resuspended. This eliminates the intramural and interarterial course and creates a neo-ostium without angulation or slit-like opening. For abbreviations, see .

Coronary artery reimplantation. Anomalous LCA arising from the RCS. A, Before repair. B, Coronary artery is detached with button of aortic tissue and reimplanted above correct sinus. Placement is slightly superior to avoid kinking. For abbreviations, see .

Lateral PA translocation. Anomalous RCA from the LCS with single ostium and normal proximal course. A, Main PA is transected at the bifurcation and left branch PA is opened along line. B, Main PA is translocated and reimplanted on the left PA, and original site is closed with pericardial patch. This moves the main PA laterally, toward the left, and reduces possible compression of anomalous artery.

“Fenestration”/limited unroofing. A, Anomalous left main coronary artery arising from the wrong coronary sinus with low intramural course, below sinotubular junction. B, Fenestration: a limited unroofing is performed only in the correct coronary sinus, creating a neo-ostium without angulation, in the correct coronary sinus, and eliminating the interarterial course, without disturbing the aortic valve commissure.