Congenital: Anomalous Aortic Origin of Coronary Artery
Outcomes of a protocolized approach for surgical unroofing of intramural anomalous aortic origin of coronary artery in children and adults

Read at the 102nd Annual Meeting of The American Association for Thoracic Surgery, Boston, Massachusetts, May 14-17, 2022.
https://doi.org/10.1016/j.jtcvs.2022.11.037Get rights and content

Abstract

Objective

Management of anomalous aortic origin of coronary arteries has been variable, and limited data are available on early and late outcomes.

Methods

We report a single institution's experience with a protocolized approach to 148 consecutive patients who underwent surgical unroofing of intramural anomalous aortic origin of coronary arteries (June 2003 to December 2020). The management algorithm included preoperative and postoperative cross-sectional and echocardiographic imaging, exercise testing, and a standardized operative technique.

Results

The median age of the cohort was 44.4 years (range, 4 months to 83 years); 130 patients had an anomalous right coronary artery, and 19 patients had an anomalous left coronary artery. Surgical unroofing was an isolated procedure in 118 patients (80%) and a concomitant procedure in 30 patients (20.3%). There were 2 (1%) early deaths; both were reoperations for aortic root or valve replacement. Over a median follow-up of 9.5 (interquartile range, 5-12.3) years, there were 5 late deaths, 3 due to noncardiac causes and 2 due to unknown cause. Late survival after anomalous aortic origin of coronary arteries repair at 10 and 15 years was 94.5% and 94.5%, respectively. There were no early or late deaths in the pediatric cohort with a median follow-up of 10.9 years (interquartile range, 6.9-12.1). At a median clinical follow-up of 3.9 years (interquartile range, 1.1-9.5), 36 patients had chest pain but none with evidence of ischemia related to the unroofing.

Conclusions

Surgical unroofing of anomalous aortic origin of coronary arteries can be performed safely with low early mortality, even in the setting of concomitant procedures. Late survival is excellent, with the vast majority being symptom free.

Section snippets

Materials and Methods

We retrospectively reviewed a total of 148 consecutive patients who underwent surgical unroofing of intramural AAOCA between June 2003 and December 2020 at our institution. Other types of AAOCA, such as intraseptal course or left anterior descending off the right sinus traveling across the right ventricular outflow tract, were not included as part of this study. Research authorization for use of medical records was obtained from all patients, and the Mayo Clinic Institutional Review Board

Results

The median age of the study cohort was 44.4 years (range, 4 months to 83 years) with 40.5% (n = 60) female. The majority were adult patients (80.4%); however, there were 29 patients aged less than 18 years with a median age of 14 years (IQR, 10-16). The AAOCA was an anomalous right coronary artery arising from the left sinus in 130 patients (87.8%), anomalous left coronary artery from the right sinus in 17 patients (11.5%), and anomalous left coronary from the noncoronary sinus in 1 patient (

Discussion

In this large institutional experience with patients having AAOCA, surgical unroofing was performed safely with excellent early outcomes. There was no operative mortality in isolated unroofing and no operative mortality in the pediatric cohort. Overall late survival at 15 years was 94%. Although a minority of patients demonstrated symptoms over follow-up, upon workup none of these patients had ischemia related to AAOCA or the unroofing. All patients were able to resume their activities without

Conclusions

Surgical unroofing of AAOCA can be performed safely even in the setting of concomitant procedures. Management of AAORCA continues to be challenging and requires numerous imaging studies correlated with clinical status and shared decision-making. A protocolized approach has resulted in excellent early results and late survival, with the vast majority being symptom-free.

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