Surgical technique
Surgery was made by anterior median sternotomy and cardiopulmonary
bypass. Myocardial protection was obtained by a single initial infusion
in the aortic root of the Bretschneider
histidine-tryptophan-ketoglutarate (HTK) solution, commercially knows as
Custodiol (Custodiol HTK, Köhler Chemie GmbH, Bensheim, Germany).
Surgical techniques employed were based on anatomic preoperative
evaluation and intraoperative findings. The purpose of surgical
management was the restoration of the best geometric take-off of the
coronary from the aorta. In all cases a careful detection of the
external course of the anomalous artery was made before aortic cross
clamp in order to define the spatial relationship of the coronaries with
the surrounding structures and to localize the point where the anomalous
artery left perpendicularly the aortic wall (defined the real take-off).
Surgical unroofing was attempted in cases of AAOCA with intramural
course. The aorta was opened and the length and direction of the
intramural segment within the aortic wall was identified. The dome of
intramural segment was incised by knife and incision was prolonged until
the real coronary artery orifice in the aorta was visualized. This real
orifice matched in all cases the external vessel perpendicularly to the
aortic wall. The intimal layer was reinforced with 7/0 polypropylene
separate stiches. When the intramural course was below the plane of
aortic valve commissures, the commissures were detached and then
resuspended to the aortic wall. This maneuver was required only in one
case in our experience.
If no intramural course but single coronary ostia was present two
different techniques were used. In one case of AAOLCA a leftward
repositioning of main pulmonary trunk was made at the beginning of our
experience. Subsequently, in other three cases (2 AAOLCA and 1 AAORCA)
the technique of neo-ostioplasty described by Vouhé and coll. [17]
was used. When no intramural course but separate ostia were present the
anomalous coronary artery was mobilized and re-implanted in the
appropriate coronary sinus (2 AAOLCA and 1 AAORCA). Associated
procedures were made in three patients (12%) patients and were the
following: one patient with tricuspid insufficiency due to annular
dilatation received a tricuspid valve repair by implantation of
artificial ring. A second patient with associated large ostiumsecundum atrial septal defect underwent to concomitant closure of
the ASD with autologous untreated pericardial patch. A third patients
have a myocardial bridge associate to AAORCA. The myocardial bridge
involved left interventricular artery and its extended for 20 mm in
length and 4 mm in deepness. The patient underwent to myocardial
muscular de-bridging by muscular unroofing.