Right coronary artery with high takeoff

Anomalous origin of the right coronary artery is an extremely rare anomaly. We describe the case of a patient whose right coronary artery was arising from the ascending aorta with high takeoff. We diagnosed the anomaly incidentally during the operation. After transverse aortotomy for aortic valve replacement, we recognized the transection of the right coronary artery. The right coronary artery ostium was located approximately 5 cm above the right sinus of Valsalva. It was showing a complete transmural course. We repaired the right coronary artery by bypassing it with a saphenous vein graft.     

Arterial switch operation with a single coronary artery

OBJECTIVE: Our purpose was to evaluate the impact of coronary pattern on survival and reintervention in patients who underwent the arterial switch operation with a single coronary artery. METHODS: We conducted a retrospective analysis of 53 patients with a single coronary artery who underwent the arterial switch operation between 1983 and 2000 at Children's Hospital Boston. Recent follow-up information was obtained for 40 of the 46 long-term survivors (mean follow-up 7.3 +/- 4.5 years). RESULTS: Thirty-five patients had a single right coronary artery, with the left coronary artery posterior to the pulmonary artery in 27. Eighteen patients had a single left coronary artery (16 with the right coronary artery anterior to the aorta). Six of 7 total patients who died had a single right coronary artery; all died before 1992. There were 5 early deaths, all with a single right coronary artery, with 4 deaths due to coronary malperfusion. Survivals for all patients were 91% at 6 months and 87% at 1, 5, and 10 years after the arterial switch operation. Survival figures were lower for patients having a single right ostium with the left main coronary artery posterior to the pulmonary artery compared with all other subtypes (P =.02, log-rank test). Seven patients had reintervention, 4 because of right ventricular outflow tract obstruction, 1 for heart transplantation, 1 for mitral valve repair and 1 for pacemaker implantation. Freedom from reintervention for all patients was 96% at 6 months, 92% at 1 year, 86% at 5 years, and 82% at 10 years after the arterial switch operation, with lower rates for patients having a single left ostium with the right coronary artery anterior to the aorta (P =.0003, log-rank test). CONCLUSIONS: In the current era, the arterial switch operation with a single coronary artery can be performed safely irrespective of the coronary anatomy. Risk of reintervention is higher in patients having a single left ostium with the right coronary artery anterior to the aorta.     

Right coronary translocation for anomalous origin of right coronary artery from the left coronary sinus

We describe right coronary translocation as a simplified surgical procedure for right coronary artery arising from the left sinus with an intramural course. At surgery, the right coronary artery was transected, distal to the intramural segment and subsequently anastomosed to the ascending aorta above the right coronary sinus. This translocation was performed in four consecutive patients with good early and medium-term results. This technique of right coronary translocation is an alternative strategy to coronary artery bypass or the unroofing technique.     

Iatrogenic right coronary artery dissection with retrograde extension to the right coronary sinus

Iatrogenic coronary artery dissection extending into the aorta is a rare condition. We report a case in a 46-year-old male patient who had dissection of the right coronary artery which occurred during diagnostic coronary catheterization. The dissection extended retrogradely to affect the right coronary sinus. The patient was treated successfully by coronary artery bypass grafting with repair of the aortic dissection.     

Surgical correction of congenital left coronary artery-main pulmonary artery fistula in association with anomalous right coronary artery.

The association of a left coronary artery-main pulmonary artery fistula and an anomalous right coronary artery originating from the main pulmonary artery is the subject of this report. This unique combination of congenital cardiac anomalies establishes a double coronary steal from the left coronary artery, which hemodynamically represents the sole source of myocardial perfusion. The left coronary artery-main pulmonary artery fistula was closed and the coexisting anomalous right coronary artery reimplanted into the anterior aspect of the ascencing aorta. A dual coronary supply was therefore established and thus eliminated the potential threat of total myocardial ischemia should the left coronary artery become critically compromised. Patency of both the left coronary artery and the transplanted right coronary artery was documented 1 year postoperatively by aortic root angiography.     

Reimplantation of anomalous right coronary artery arising from the pulmonary trunk leading to normal coronary flow reserve late after surgery

We report a case of successful reimplantation of the right coronary artery from the pulmonary trunk into the aorta with a 10-year follow-up. The finding of a normal coronary flow reserve late after surgery suggests that direct reimplantation of the right coronary artery into the aorta is the preferable surgical technique.     

A simple distal coronary perfusion technique in off-pump coronary artery bypass.

This communication describes the surgical technique and clinical outcomes of a simple coronary perfusion technique for use during off-pump coronary artery bypass grafting. An intra-coronary shunt tube connected to the graft conduit (saphenous vein or radial artery) with an arterial blood source (ascending aorta or right internal thoracic artery) was inserted distally via a coronary arteriotomy for temporary perfusion of six left anterior descending arteries and two right coronary arteries.     

High origin of the right coronary artery with congenital heart disease

We encountered a case of anomalous high origin of the right coronary artery associated with ventricular septal defect and patent ductus arteriosus. The right coronary artery originated from the distal part of the ascending aorta resulting in unsuccessful induction of cardiac arrest by cardioplegia. We describe this rare case with anomalous origin of the right coronary artery.     

Left main coronary bypass for aberrant (aortic) intramural left coronary artery.

This report describes the first saphenous vein bypass graft from the aorta to the left main coronary artery for an aberrant left main coronary artery arising from the anterior sinus of Valsalva. A 20-year-old college student had a cardiac arrest and documented ventricular fibrillation while jogging. He was resuscitated. An anomalous left main coronary artery, arising anteriorly from the right coronary sinus, was demonstrated at operation to be within the wall of the aorta. Following aorta--left main coronary artery bypass with the saphenous vein, results of a stress test were normal, and cardiac catheterization revealed the left coronary system to be entirely supplied by the graft.     

Off-pump coronary bypass using interposed radial artery graft

We describe a patient with severely diseased ascending aorta and small internal mammary arteries, who underwent off-pump coronary artery bypass to the left anterior descending coronary artery and right coronary artery using composite arterial grafts consisting of the pedicled proximal internal mammary artery and interposed radial artery graft. The interposed radial artery graft provides advantages, such as making coronary anastomosis on the beating heart easier and to increasing the flow potentiality of the internal mammary artery.     

Pulmonary artery translocation: a surgical option for complex anomalous coronary artery anatomy

Rather than perform a difficult and potentially high risk coronary reimplantation in a patient with an aberrant right coronary artery coursing between the aorta and pulmonary artery, the main pulmonary artery was translocated toward the left pulmonary hilum to create additional space between the aortic and pulmonic trunks.     

The left gastric artery as an in-situ conduit in coronary artery bypass grafting

Unsuitability of the in-situ right gastroepiploic artery in coronary bypass grafting occurs. Sometimes free-grafting can be performed, although this should not be considered in patients with a diseased ascending aorta. We describe the successful use of the left gastric artery as an alternative in-situ arterial conduit in a patient with a severely atherosclerotic ascending aorta.     

The use of the right gastro-epiploic artery in coronary artery bypass grafting

Thirty consecutive patients with angina pectoris undergoing coronary artery bypass grafting using the proximally attached right gastro-epiploic artery are described. Posterior coronary arteries were grafted using the right gastro-epiploic artery, and grafts to the left coronary artery were done using predominantly internal mammary artery grafts. The right gastro-epiploic artery graft is mobilized along the greater curvature of the stomach, and transected distally. With cardiopulmonary bypass and blood cardioplegic arrest for myocardial preservation during cross-clamping of the aorta, the distal end of the artery is anastomosed end-to-side to the posterior descending artery or a postero-lateral branch, or to both, using a sequential technique. Twenty-five of the patients complained of symptoms suggestive of angina early postoperatively but are currently symptom-free with normal exercise tolerance. Thirteen patients had postoperative exercise tests: eight were normal, two were inconclusive, and three were abnormal. Nine grafted coronary arteries were re-angiogrammed, and seven were judged to be patent. It is concluded that, as an alternative resource, the right gastro-epiploic artery can be used to bypass coronary obstructions expeditiously and with results comparable to those obtained with the saphenous vein or internal mammary artery.     

Minimally invasive direct coronary artery bypass grafting using the gastroepiploic artery for reoperation after the cabrol procedure

Obstruction of the right coronary ostial anastomosis is a rare late complication after composite graft replacement of the ascending aorta and the aortic valve with separate Dacron coronary grafts (Cabrol method). Occlusion at the right coronary ostial anastomosis in a 36-year-old woman with aortitis syndrome who underwent a composite graft with a Dacron coronary graft is described. She underwent a third successful operation for right coronary reconstruction by minimally invasive direct coronary artery bypass grafting technique using the right gastroepiploic artery. This approach is likely to be extremely useful in avoiding resternotomy and cardiopulmonary bypass in patients requiring coronary reoperation.     

Treatment of acute aortic dissection involving the right coronary artery and aortic valve

A complication of acute dissection of the ascending aorta is involvement of the aortic valve and right coronary artery. A case is presented in which the treatment of this lesion involved placement of a composite valve graft with reattachment of the left main coronary artery using a small Dacron tube graft and a saphenous vein bypass to the right coronary artery.     

Porcelain aorta in coronary artery bypass graft operations: an alternative approach

Porcelain aorta represents a serious condition for coronary artery bypass graft operations. Here we describe a simple technique to avoid any aortic manipulation during an off-pump coronary artery bypass graft procedure. The right internal thoracic artery is used as the source of blood inflow for single or sequential venous grafts. We have used this technique with good results in 5 elderly patients with eggshell aorta.     

A case report of Bentall procedure for annulo-aortic ectasia associated with right coronary artery dissection

A 30-year-old man who had annuloaortic ectasia associated with aortic insufficiency owing to marked annular dilatation was treated by replacement of the ascending aorta and aortic valve with a composite graft. It was necessary to transpose the origin of the coronary artery because of the development of dissection to right coronary ostia. We have applied the Bentall procedure with aorta coronary bypass between the right coronary artery and the aortic prosthesis with the use of saphenous vein graft. His post operative course is uneventful and engaging full work 18 month after operation. This technique is useful for the case of annuloaortic ectasia associated with difficulty coronary anastomosis such as coronary artery dissection, obstruction or dislocation.     

Simultaneous coronary artery bypass grafting and ascending aorta bifemoral bypass in small aorta syndrome.

A 55-year-old man with severe coronary artery disease and aortoiliac occlusive disease with small aorta syndrome was admitted to our department with angina pectoris and bilateral claudication. Intravenous subtraction angiography showed total occlusion of the right common iliac artery and 99% stenosis of the left common iliac artery with a markedly hypoplastic infrarenal aorta only 9 mm in diameter. It also revealed 90% stenosis at the origin of the left subclavian artery. Coronary angiography showed total occlusion of the left anterior descending artery and 90% stenosis of the circumflex artery. Simultaneous coronary artery bypass grafting and an ascending aorta-bifemoral bypass were conducted using an in-situ right internal mammary artery graft, an autologous saphenous vein graft, and a Y-figured expanded polytetrafluoroethylene graft. Postoperative angiography showed grafts to the coronary and bifemoral arteries were patient. This combined procedure is useful for patients with coronary artery disease and aortoiliac occlusive disease, especially in those with small aorta syndrome.     

Minimally invasive direct coronary artery bypass grafting using the gastroepiploic artery for reoperation after the Cabrol procedure.

Obstruction of the right coronary ostial anastomosis is a rare late complication after composite graft replacement of the ascending aorta and the aortic valve with separate Dacron coronary grafts (Cabrol method). Occlusion at the right coronary ostial anastomosis in a 36-year-old woman with aortitis syndrome who underwent a composite graft with a Dacron coronary graft is described. She underwent a third successful operation for right coronary reconstruction by minimally invasive direct coronary artery bypass grafting technique using the right gastroepiploic artery. This approach is likely to be extremely useful in avoiding resternotomy and cardiopulmonary bypass in patients requiring coronary reoperation.     

Acute aortic dissection with anomalous coronary artery

A 38-year-old man was diagnosed with acute type A aortic dissection and severe aortic regurgitation, and taken immediately to the operating room for repair of the ascending aorta using the Bentall procedure. The presence of the anomalous right coronary artery was revealed at the time of the procedure, and was repaired with single coronary button technique. Some case reports have described anomalous coronary artery in association with acute myocardiac infarction or angina pectoris. This report describes a case of anomalous coronary artery diagnosed during an emergency operation for aortic dissection.