Treatment of coronary anomalies in adults

Objectives: Incidence of coronary anomalies is unknown. Symptoms in adults occur after the 4^th decade; sudden death has been reported. CABG with intern thoracic arteries or veins has proven inefficient.

Methods: Five patients (3 male, 48.6 ± 8.4 years) with variable symptoms of angina had normal coronary angiography except for the difficulty to inject into the RCA. 3D-MRI/CT scan showed an atypical origin of the RCA in the left coronary sinus running between the aorta and the pulmonary artery.

Surgery addressed all three components of the anomaly (orifice without a funnel, intramural course, location between pulmonary artery and aorta). Surgical steps were: aortotomy, unroofing of the ostium distally to the pulmonary artery throughout the intramural course and additional in-situ RITA Bypass to protect in case of early occlusion of the reconstruction.

Results: Intraoperative course was uneventful. Patency of the reconstruction was proven by increase of the RITA flow under transient occlusion of the proximal RCA. All patients were extubated on day 1. One patient had sudden cardiac fibrillation on the ICU with emergent ECMO implantation and revision of the dissected RITA. The patient recovered and was discharged with normal LV-function. At follow-up of (15 ± 9 months), all patients are clinically well without cardiac symptoms. Control MRI in one patient showed an occluded RITA graft and a “normal” RCA.

Conclusion: Angina in mid-aged patients without coronary artery disease may be caused by coronary anomalies. Anatomical reconstruction with bypass is a convincing surgical strategy. The indication is still intriguing as neither the incidence nor the clinical impact are known.