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Asian Cardiovascular
and Thoracic Annals
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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
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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
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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: kamalessk@gmail.com
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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
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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.
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