Surgery for anomalous aortic origin of the coronary artery

Background: Anomalous aortic origin of the coronary artery (AAOCA) has been associated with coronary ischemia, myocardial infarction, and sudden death. Advances in echocardiography and computed tomography have identified at-risk patients. Treatment options include unroofing strategies in symptomatic and asymptomatic patients. We review our experience for efficacy and safety. Methods Between 1998 and 2008, we performed coronary unroofing in 22 patients with AAOCA without aortic commissural detachment. Of 7 patients with "left from right" AAOCA, 4 had chest pain only, 1 had syncope, 1 had myocardial infarction, and 1 was asymptomatic. Of 15 patients with "right from left" AAOCA, 11 had chest pain only, 4 had syncope, and none were without symptoms. Median age was 15 years (range, 5 to 54). Eight patients had concomitant procedures, most commonly patent foramen ovale closure. Results There were no deaths or complications. Mean cross-clamp time was 53 minutes. Mean length of stay was 4 days. Postoperative evaluation included echocardiography, computed tomography angiogram, stress thallium, stress echocardiography, and exercise stress test. In all patients, the repaired coronary was patent, with demonstrated flow. Mean follow-up was 17 months (range, 1 to 63). Conclusions Anomalous aortic origin of the coronary artery is emerging as an identifiable disease entity associated with symptoms or sudden death. We conclude that coronary unroofing is a safe and effective therapy for symptomatic patients. Surgery for asymptomatic patients has been more controversial, with growing advocacy for patients with "left from right" as opposed to "right from left" origins. Prospective studies will be required to answer these questions.