Anomalous Origin of the RCA—Tailoring Operative Strategy in Complex Aortic Pathology

O. A.. Jarral¹, S. Pupovac², D. Brinster^3
1Northwell Health - Lenox Hill, NYC, New York ²Northwell, Northshore University Hospital, Manhasset, New York ³Northwell Health - Lenox Hill, New York, New York

Please explain the educational or technical point that this video addresses.: This video focuses on technical aspects of managing the anomalous RCA whilst patients are undergoing concomitant aortic root intervention. Specifically, it focuses on how surgeons need to be adept at the following three surgical techniques: unroofing, reimplantation, reimplantation with a conduit extension, and lastly CABG with end to side reimplantation of the anomalous vessel.

Please provide a 250 word summary of the surgical video being submitted.: Anomalous origin of the right coronary artery from the left sinus has an incidence of 0.33%. More cases are being seen as a result of increasing imaging screening. When intervention is required, the morbidity from this is nontrivial, including recurrent ischemia and symptoms. Recurrent ischemia is often something that can be avoided with appropriate decision making and surgical technique. In patients with concomitant aortic root pathology (for example, those undergoing valve sparing root replacement), further complexity is added as a result of longer clamp times, potential myocardial protection issues if the RCA ostia is very small, the risks of thrombosis with small vessel anastamosis to dacron, the risk of thrombosis with the use of blood products/factors, and lastly challenging aortic root geometries which increase the risk of kinking at the RCA proximal anastamosis.

In this video, we present our tailored approach to the management of interarterial anomalous RCA from the left coronary sinus in patients with complex aortic root pathologies. High quality videos are presented demonstrating that surgeons need to be versatile in their approach, and the specific situations when one must pivot from unroofing to reimplantation, or reimplantation with a conduit extension +/- CABG.