Anomalous Aortic Origin of the Coronary Arteries: A Novel Unroofing Technique in an Adult Cohort

Background. Anomalous aortic origin of the coronary arteries (AAOCA) is associated with sudden cardiac death and frequently treated with unroofing of an intramural segment. Most reports on AAOCA are of patients less than 30 years of age. We have reviewed our older patients who have undergone surgical repair and report a novel unroofing technique. Methods. A retrospective review was conducted of 40 adult patients who underwent surgery for AAOCA from June 2005 to June 2016. Our surgical approach changed from traditional sharp excision to electrical fulguration of the shared intramural wall segment. We assessed our population for symptom relief, resolution of ischemia, and reintervention. More than 6 months of follow-up was available for 34 patients. Results. Mean age was 47.1 +/- 11.6 years (range, 19 to 67); 17 patients were female. The coronary anomaly was right from left in 35 patients, left from right 4, and left coronary from noncoronary sinus in 1 patient. Thirty-nine of 40 patients were symptomatic, with two prior sudden cardiac arrests. Preoperatively, 22 of 31 patients tested positive for ischemia, including the asymptomatic. The operation was unroofing in 37 of 40 patients, 17 by sharp excision and 20 by electrical fulguration. There were no 30-day deaths or complications and no reinterventions. Isolated unroofing by fulguration required shorter cardiopulmonary bypass and cross-clamp times than excision: 39 versus 62 minutes (p = 0.02) and 28 versus 42 minutes (p = 0.02), respectively. At an average follow-up of 5.0 years, 28 of 34 patients reported symptomatic improvement. There were two unrelated late deaths. Conclusions. Unroofing by sharp excision and by electrical fulguration were equally safe in the short term. Fulguration is technically easier and faster while still equally effective. (C) 2019 by The Society of Thoracic Surgeons