This case demonstrates surgical unroofing for an anomalous right coronary artery with a tight intramural course in a 38-year-old woman with lifelong chest pain and exertional dyspnea. Intraoperative images and postoperative CTA highlight restoration of a widely patent neo-ostium with durable symptom resolution at five-year follow-up.
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Anomalous aortic origin of the coronary artery. This is a case study of a 38 year old female patient with chest pain throughout her life and ongoing exertional dyspnea, who was found on workup to have an anomalous right coronary with a tight intramural course. She was taken to the operating room for an unroofing. The video is narrated to describe. Here the chest is open. You can see the aorta superiorly and the right ventricle inferiorly. Right now we are working around the aorta. We proceed to put the patient on the heart lung machine and then stop the heart. The aorta is being opened and we are identifying the ostia or openings of the coronary arteries. And the anomalous coronary is difficult to visualize but is identified using a probe. You can see it is close, almost under the area where the aortic valve attaches, or the post. Now the unroofing begins. Fine scissors are inserted into the coronary to identify the direction of the coronary artery, and then the tissue or roof above the coronary artery is cut. This leaves a ridge of tissue on either side of the coronary artery that is then tacked down with multiple fine sutures. This process is continued with the roof being cut and the sutures being placed on either side. We have gone past the place where the aortic valve attaches and are continuing into the right sinus. In this case, this is the normal sinus from which the coronary artery arises. As you can see, the coronary is still continuing within the wall itself parallel to the aorta. This unroofing is continued until the artery dives away from the wall into the myocardium. At this point, the coronary has been completely unroofed. Shown here is the final result, you can see the coronary has a wide open osteo or hole for unobstructed blood flow. In this case, because of the coronary course, the aortic valve attachment or post is at risk for drooping down and leading to aortic regurgitation. So we place an additional stitch to stabilize that post, which is the blue stitch on the right being held by the instrument. We then close the aorta, putting down the last knots here, and proceed to take the patient off the heart lung machine. Shown here the heart is starting to beat again. Here we can see intraoperative photos depicting the anatomy. On the left, the origin of the anomalous right coronary can barely accept a small coronary probe through the slit-like orifice. The large left main ostium is also visible. On the right panel we can see the neoostium is widely patent after the unroofing. Shown here is her postoperative CTA demonstrating a widely patent right coronary arising from the proper right sinus. Postoperatively, her chest pain resolved, and she is now 5 years out from surgery.
