Intramural Coronary Length Correlates With Symptoms in Patients With Anomalous Aortic Origin of the Coronary Artery Sunjay Kaushal, MD, PhD, Carl L.

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Intramural Coronary Length Correlates With Symptoms in Patients With Anomalous Aortic Origin of the Coronary Artery Sunjay Kaushal, MD, PhD, Carl L. Backer, MD, Andrada R. Popescu, MD, Brandon L. Walker, MS, Hyde M. Russell, MD, Peter R. Koenig, MD, Cynthia K. Rigsby, MD, Constantine Mavroudis, MD The Annals of Thoracic Surgery Volume 92, Issue 3, Pages 986-992 (September 2011) DOI: 10.1016/j.athoracsur.2011.04.112 Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Anomalous aortic origin of the right coronary artery from the left sinus of Valsalva is shown. (A) The transected aortic root demonstrates an intramural course of the right coronary artery above the aortic valve commissure and with its ostium in the left sinus of Valsalva. The left coronary artery has a normal orifice and course. (B) The unroofing technique is performed with a #11 blade along the entire course of the intramural coronary artery until the coronary artery exits away from the aortic wall. (C) Tacking sutures of 8-0 Prolene are placed around the neo-ostium to prevent intimal dissection or thrombosis. (Reprinted from Oper Tech Thorac Cardiovasc Surg, Vol. 15, Mavroudis C, Backer CL, Technical Tips for Three Congenital Heart Operations: Modified Ross-Konno Procedure, Optimal Ventricular Septal Defect Exposure by Tricuspid Valve Incision, Coronary Unroofing and Endarterectomy for Anomalous Aortic Origin of the Coronary Artery, pages 18–40, Copyright 2010, with permission from Elsevier [14]). The Annals of Thoracic Surgery 2011 92, 986-992DOI: (10.1016/j.athoracsur.2011.04.112) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 The (A) anatomy, (B) unroofing procedure, and (C) ostial suture placement are shown for an anomalous aortic origin of the left coronary artery from the right sinus of Valsalva. (Reprinted from Oper Tech Thorac Cardiovasc Surg, Vol. 15, Mavroudis C, Backer CL, Technical Tips for Three Congenital Heart Operations: Modified Ross-Konno Procedure, Optimal Ventricular Septal Defect Exposure by Tricuspid Valve Incision, Coronary Unroofing and Endarterectomy for Anomalous Aortic Origin of the Coronary Artery, pages 18–40, Copyright 2010, with permission from Elsevier [14]). The Annals of Thoracic Surgery 2011 92, 986-992DOI: (10.1016/j.athoracsur.2011.04.112) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 (A) A computed tomography scan shows a left anomalous aortic origin of the left coronary artery (AAOCA). (B) Scan shows the same patient after coronary unroofing. The coronary orifice has been moved to the left sinus of Valsalva and appears widely patent. (C) A computed tomography scan shows a right AAOCA. (D) Scan shows the same patient after coronary unroofing. (E) A computed tomography scan shows an endoluminal view of a right AAOCA from the left sinus with a normal left coronary artery ostium (white arrow) and slit-like right coronary artery (white arrowhead). The Annals of Thoracic Surgery 2011 92, 986-992DOI: (10.1016/j.athoracsur.2011.04.112) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Data are shown for the length of intramural coronary artery in patients with (blue) and without (red) symptoms. A greater intramural coronary length measured by preoperative imaging (computed tomography or magnetic resonance imaging) or by direct intraoperative measurement correlated with preoperative symptoms. The error bars show the standard deviation. *p < .001. (CT = computed tomography.) The Annals of Thoracic Surgery 2011 92, 986-992DOI: (10.1016/j.athoracsur.2011.04.112) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions