Asian Cardiovascular and Thoracic Annals http://aan.sagepub.com/ Aortic root replacement with absent left-main coronary artery: how to do it Kamales Kumar Saha, Bhupesh Parate and Bharat Jagiasi Asian Cardiovascular and Thoracic Annals published online 25 October 2013 DOI: 10.1177/0218492313501680 The online version of this article can be found at: http://aan.sagepub.com/content/early/2013/10/25/0218492313501680 Published by: http://www.sagepublications.com On behalf of: The Asian Society for Cardiovascular Surgery Additional services and information for Asian Cardiovascular and Thoracic Annals can be found at: Email Alerts: http://aan.sagepub.com/cgi/alerts Subscriptions: http://aan.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav >> OnlineFirst Version of Record - Oct 25, 2013 What is This? Downloaded from aan.sagepub.com by guest on September 22, 2014 XML Template (2013) [16.8.2013–3:54pm] //blrnas3/cenpro/ApplicationFiles/Journals/SAGE/3B2/AANJ/Vol00000/130407/APPFile/SG-AANJ130407.3d (AAN) [1–3] [PREPRINTER stage] Case Study Aortic root replacement with absent left-main coronary artery: how to do it Asian Cardiovascular & Thoracic Annals 0(0) 1–3 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313501680 aan.sagepub.com Kamales Kumar Saha, Bhupesh Parate and Bharat Jagiasi Abstract Aortic root replacement in patient with a coronary artery anomaly can be challenging. We describe aortic root replacement in a patient with annuloaortic ectasia and coarctation, who had an absent left main coronary artery. There were separate origins of the left anterior descending and left circumflex coronary arteries from the aorta. The technical modification employed in this case is discussed. Keywords Aorta, Aortic coarctation, Blood vessel prosthesis implantation, Cardiac surgical procedures, Coronary vessel anomalies, Incidental findings Introduction Aortic root replacement in a patient with a coronary artery anomaly can be challenging. We describe the surgical technique used for aortic root replacement in a patient who had separate origins of the left anterior descending (LAD) and left circumflex (LCX) coronary arteries from the left aortic sinus. Case report A 30-year-old man presented with an ascending aortic aneurysm, severe aortic regurgitation, and left ventricular dysfunction with an ejection fraction of 20%. He had coarctation of the aorta treated by a percutaneous intervention, and was found to have congestive cardiac failure due to poor ventricular function. He underwent aortic root replacement after intensive decongestive therapy. The procedure was started in the usual fashion. After opening the pericardium, the anatomy was examined (Figure 1). A combination of alternate retrograde coronary sinus and direct coronary ostial blood cardioplegia was used. After opening the aorta, separate origins of the LAD and LCX were noted. The LAD arose cranial and lateral to the origin of the LCX (Figure 2). A larger left coronary button was created, keeping enough aortic tissue around both coronary ostia (Figure 3). Mobilization of the button was difficult because the LCX course was posterior and the LAD course was lateral. We initially used a coronary probe to assess the course of the coronary artery. While mobilizing the button, an intracoronary shunt (2.0 mm) was placed inside the ostium; this helped with easy recognition of the coronary artery during mobilization. The right coronary button was mobilized in the usual fashion. A valved conduit was sutured to the aortic annulus using 2/0 interrupted pledgetted polyester suture, with the pledgets on the aortic side. After seating the valve, a second layer of continuous suture of 3/0 polypropylene was used between the annulus and the valve sewing ring, with Teflon felt on the annulus side. The coronary buttons were implanted into the conduit using 5/0 polypropylene continuous suture in the usual fashion. A hood was created for the left coronary button, using excess aortic tissue attached to the coronary button in a similar fashion to that described by Westaby and colleagues1,2 who used a pericardial patch, but instead of attaching a pericardial patch to the button, excess aortic wall of the button was used. This helped to prevent any tension or kinking of the MGM New Bombay Hospital, Mumbai, India Corresponding author: Kamales Kumar Saha, MCh, C-801/802 Raheja Sherwood, Behind Hub Mall, Off Western Express Highway, Nirlon Compound, Goregaon East, Mumbai 400063, India. Email: [email protected] Downloaded from aan.sagepub.com by guest on September 22, 2014 XML Template (2013) [16.8.2013–3:54pm] //blrnas3/cenpro/ApplicationFiles/Journals/SAGE/3B2/AANJ/Vol00000/130407/APPFile/SG-AANJ130407.3d (AAN) [1–3] [PREPRINTER stage] 2 Asian Cardiovascular & Thoracic Annals 0(0) Figure 1. Operative photograph showing the large ascending aortic aneurysm. Figure 2. The large coronary button revealed separate origins of the left anterior descending and left circumflex coronary arteries. coronary artery. Fibrin glue was used after the coronary buttons were sutured. The graft was anastomosed to the ascending aorta in two layers: the first layer using 3/0 polypropylene, and the second layer using 4/0 polypropylene with a Teflon felt strip on the aortic side. Warm retrograde reperfusion was used while performing the anterior layer of the conduit-to-aorta anastomosis, thus when we finished that anastomosis, the heart had started beating. The rest of the operation was completed in the usual manner. hood extension of the coronary buttons.1 In our patient, the LAD and LCX arose separately, and both were included in a larger than usual button. We kept the excess of the aortic wall, which was used in a similar fashion to that described by Westaby and colleagues.1 Instead of attaching a pericardial hood to the aortic button, the excess aortic tissue was used. The LAD course was lateral and the LCX course was posterior. Creating a hood of aortic wall ensured that there was no tension on the coronaries, even with limited mobilization. The other challenge was to mobilize the coronary artery without any damage. In the presence of a coronary anomaly, it may be difficult to assess the course of the coronary artery, particularly if it has an intramural course. We suggest the use of a coronary probe to assess the course of the artery. While mobilizing the artery, an appropriate size of intracoronary shunt (used for off-pump coronary bypass surgery) can be kept inside the artery. Using a coronary shunt inside the ostium was of immense help in protecting the coronary artery during mobilization. Discussion There are reports in the literature of aortic root replacement in patients with a single coronary ostium.3,4 After an extensive search, we could not find any report of aortic root replacement in a patient with separate coronary artery origins. Unexpected anatomical problems during aortic root replacement demand innovative solutions.5 If it is not possible to perform coronary implantation, the options include coronary bypass, coronary extension using a Dacron conduit, or pericardial Downloaded from aan.sagepub.com by guest on September 22, 2014 XML Template (2013) [16.8.2013–3:54pm] //blrnas3/cenpro/ApplicationFiles/Journals/SAGE/3B2/AANJ/Vol00000/130407/APPFile/SG-AANJ130407.3d (AAN) [1–3] [PREPRINTER stage] Saha et al. 3 is extremely rare. This was not diagnosed preoperatively because angiography was not performed. Routine preoperative delineation of the coronary anatomy should be performed even in a young patient, for better planning of aortic root replacement. Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors. Conflict of interest statement None declared References Figure 3. The left coronary button with sufficient tissue around the ostia. This picture shows the size of the button relative to the suction tip. Aortic root replacement with coronary reimplantation is possible in the presence of separate origins of the LAD and LCX. Separate origins of the LAD and LCX 1. Westaby S, Katsumata T and Vaccari G. Coronary reimplantation in aortic root replacement: a method to avoid tension. Ann Thorac Surg 1999; 67: 1176–1177. 2. Westaby S, Katsumata T and Vaccari G. Aortic root replacement with coronary button re-implantation: low risk and predictable outcome. Eur J Cardiothorac Surg 2000; 17: 259–265. 3. O’Blenes SB and Feindel CM. Aortic root replacement with anomalous origin of the coronary arteries. Ann Thorac Surg 2002; 73: 647–649. 4. Morimoto H, Mukai S, Obata S and Hiraoka T. Incidental single coronary artery in an octogenarian with acute type A aortic dissection. Interact Cardiovasc Thorac Surg 2012; 15: 307–308. 5. Sareyyupoglu B, Burkhart HM, Dearani JA and Connolly HM. Intramural left main coronary artery unexpectedly encountered during aortic root replacement. Ann Thorac Surg 2009; 87: 1948–1949. Downloaded from aan.sagepub.com by guest on September 22, 2014
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