Surgical technique
Surgery was made by anterior median sternotomy and cardiopulmonary bypass. Myocardial protection was obtained by a single initial infusion in the aortic root of the Bretschneider histidine-tryptophan-ketoglutarate (HTK) solution, commercially knows as Custodiol (Custodiol HTK, Köhler Chemie GmbH, Bensheim, Germany).
Surgical techniques employed were based on anatomic preoperative evaluation and intraoperative findings. The purpose of surgical management was the restoration of the best geometric take-off of the coronary from the aorta. In all cases a careful detection of the external course of the anomalous artery was made before aortic cross clamp in order to define the spatial relationship of the coronaries with the surrounding structures and to localize the point where the anomalous artery left perpendicularly the aortic wall (defined the real take-off).
Surgical unroofing was attempted in cases of AAOCA with intramural course. The aorta was opened and the length and direction of the intramural segment within the aortic wall was identified. The dome of intramural segment was incised by knife and incision was prolonged until the real coronary artery orifice in the aorta was visualized. This real orifice matched in all cases the external vessel perpendicularly to the aortic wall. The intimal layer was reinforced with 7/0 polypropylene separate stiches. When the intramural course was below the plane of aortic valve commissures, the commissures were detached and then resuspended to the aortic wall. This maneuver was required only in one case in our experience.
If no intramural course but single coronary ostia was present two different techniques were used. In one case of AAOLCA a leftward repositioning of main pulmonary trunk was made at the beginning of our experience. Subsequently, in other three cases (2 AAOLCA and 1 AAORCA) the technique of neo-ostioplasty described by Vouhé and coll. [17] was used. When no intramural course but separate ostia were present the anomalous coronary artery was mobilized and re-implanted in the appropriate coronary sinus (2 AAOLCA and 1 AAORCA). Associated procedures were made in three patients (12%) patients and were the following: one patient with tricuspid insufficiency due to annular dilatation received a tricuspid valve repair by implantation of artificial ring. A second patient with associated large ostiumsecundum atrial septal defect underwent to concomitant closure of the ASD with autologous untreated pericardial patch. A third patients have a myocardial bridge associate to AAORCA. The myocardial bridge involved left interventricular artery and its extended for 20 mm in length and 4 mm in deepness. The patient underwent to myocardial muscular de-bridging by muscular unroofing.