Surgery for anomalous origin of the left main coronary artery from the right sinus of Valsalva, in association with left main stenosis

Abstract

Most medical literature regarding the anomalous origin of a coronary artery from the opposite sinus of Valsalva pertains to sudden death in the young. The surgical treatment of anomalous origin of the left main coronary artery from the right sinus of Valsalva is not particularly well codified, and when an anomalous left main coronary artery is associated with an extramural stenosis, treatment becomes more technically challenging. Herein, we describe a unique approach toward treating this combination of conditions. A 15-year-old adolescent boy was diagnosed with anomalous origin of the left main coronary artery from the right sinus of Valsalva. The condition was accompanied by a slit ostium and an extramural stenosis of the left main coronary artery. Surgery was offered to the patient in view of his young age and the uncertain prospective course of the disease. Coronary unroofing was not indicated, due to the extramural location of the stenosis. With the patient under cardiopulmonary bypass, the stenotic segment of the left main coronary artery was transected outside the aorta, repaired by vein patch augmentation, and reimplanted directly into the left coronary sinus. The patient recovered uneventfully. A postoperative computed tomographic angiogram showed good patency of the reconstructed artery. We expect excellent longevity of the directly reimplanted coronary artery.

Keywords: Adolescent; cardiac surgical procedures; chest pain/etiology; coronary angiography; coronary vessel anomalies/classification/diagnosis/surgery; death, sudden/prevention & control; prognosis; replantation; sinus of Valsalva/abnormalities.

Fig. 1 The left main coronary artery (LMCA) with anomalous origin from the right sinus of Valsalva (white arrow). A) Preoperative coronary angiography and B) intraoperative photograph before repair. A substantial stenosis was observed in the LMCA. A slit in the LMCA ostium (black arrow) was identified just to the left of the ostium of the right coronary artery (arrowhead) in the right sinus of Valsalva.

Fig. 2 Analysis of computed tomographic angiograms of the left main coronary artery with its anomalous origin from the right sinus of Valsalva. A) Three-dimensional reconstruction shows a long, severe stenosis of intramural and extramural segments of the artery (arrow). B) Multiplanar reconstruction shows the extramural stenosis (double arrow). Ao = aorta; Cir = left circumflex coronary artery; LAD = left anterior descending coronary artery; PA = pulmonary artery

Fig. 3 Computed tomographic angiograms, 18 months after correction of the anomalous origin of the left main coronary artery from the right sinus of Valsalva. The artery was augmented with a vein patch and was reimplanted directly into the left sinus of Valsalva (arrow).