Surgery for anomalous aortic origin of coronary arteries : a multicentre study from the European Congenital Heart Surgeons Association

OBJECTIVES: We sought to describe early and late outcomes in a large surgical series of patients with anomalous aortic origin of coronary arteries. METHODS: We performed a retrospective multicentre study including surgical patients with anomalous aortic origin of coronary arteries since 1991. Patients with isolated high coronary takeoff and associated major congenital heart disease were excluded. RESULTS: We collected 156 surgical patients (median age 39.5 years, interquartile range 15-53) affected by anomalous right (67.9%), anomalous left (22.4%) and other anatomical abnormalities (9.6%). An interarterial course occurred in 86.5%, an intramural course in 62.8% and symptoms in 85.9%. The operations included coronary unroofing (56.4%), reimplantation (19.2%), coronary bypass graft (15.4%) and other (9.0%). Two patients with preoperative cardiac failure died postoperatively (1.3%). All survivors were discharged home in good clinical condition. At a median follow-up of 2 years (interquartile range 1-5, 88.5% complete), there were 3 deaths (2.2%), 9 reinterventions in 8 patients (5 interventional, 3 surgical); 91.2% are in New York Heart Association functional class <= II, but symptoms persisted in 14.2%; 48.1% of them returned to sport activity. On Kaplan-Meier analysis, event-free survival at follow-up was 74.6%. Morbidity was not significantly different among age classes, anatomical variants and types of surgical procedures. Furthermore, return to sport activity was significantly higher in younger patients who participated in sports preoperatively. CONCLUSIONS: Surgical repair of anomalous aortic origin of coronary arteries is effective and has few complications. Unroofing and coronary reimplantation are safe and are the most common procedures. The occurrence of late adverse events is not negligible, and long-term surveillance is mandatory. Most young athletes can return to an unrestrained lifestyle

Diagnostic Yield of Non-Invasive Testing in Patients with Anomalous Aortic Origin of Coronary Arteries : A Multicentric Experience

Background: Anomalous aortic origin of a coronary artery (AAOCA) is a congenital heart disease with a 0.3%-0.5% prevalence. Diagnosis is challenging due to nonspecific clinical presentation. Risk stratification and treatment are currently based on expert consensus and single-center case series. Methods: Demographical and clinical data of AAOCA patients from 17 tertiary-care centers were analyzed. Diagnostic imaging studies (Bidimensional echocardiography, coronary computed tomography angiography [CCTA] were collected. Clinical correlations with anomalous coronary course and origin were evaluated. Results: Data from 239 patients (42% males, mean age 15 y) affected by AAOCA were collected; 154 had AAOCA involving the right coronary artery (AAORCA), 62 the left (AAOLCA), 23 other anomalies. 211 (88%) presented with an inter-arterial course. Basal electrocardiogram (ECG) was abnormal in 37 (16%). AAOCA was detected by transthoracic echocardiography and CCTA in 53% and 92% of patients, respectively. Half of the patients reported cardiac symptoms (119/239; 50%), mostly during exercise in 121/178 (68%). An ischemic response was demonstrated in 37/106 (35%) and 16/31 (52%) of patients undergoing ECG stress test and stress-rest single positron emission cardiac tomography. Compared with AAORCA, patients with AAOLCA presented more frequently with syncope (18% vs. 5%, P = 0.002), in particular when associated with inter-arterial course (22% vs. 5%, P < 0.001). Conclusion: Diagnosis of AAOCA is a clinical challenge due to nonspecific clinical presentations and low sensitivity of first-line cardiac screening exams. Syncope seems to be strictly correlated to AAOLCA with inter-arterial course.Peer reviewe

Surgery for anomalous aortic origin of coronary arteries : a multicentre study from the European Congenital Heart Surgeons Association

OBJECTIVES: We sought to describe early and late outcomes in a large surgical series of patients with anomalous aortic origin of coronary arteries. METHODS: We performed a retrospective multicentre study including surgical patients with anomalous aortic origin of coronary arteries since 1991. Patients with isolated high coronary takeoff and associated major congenital heart disease were excluded. RESULTS: We collected 156 surgical patients (median age 39.5 years, interquartile range 15-53) affected by anomalous right (67.9%), anomalous left (22.4%) and other anatomical abnormalities (9.6%). An interarterial course occurred in 86.5%, an intramural course in 62.8% and symptoms in 85.9%. The operations included coronary unroofing (56.4%), reimplantation (19.2%), coronary bypass graft (15.4%) and other (9.0%). Two patients with preoperative cardiac failure died postoperatively (1.3%). All survivors were discharged home in good clinical condition. At a median follow-up of 2 years (interquartile range 1-5, 88.5% complete), there were 3 deaths (2.2%), 9 reinterventions in 8 patients (5 interventional, 3 surgical); 91.2% are in New York Heart Association functional class CONCLUSIONS: Surgical repair of anomalous aortic origin of coronary arteries is effective and has few complications. Unroofing and coronary reimplantation are safe and are the most common procedures. The occurrence of late adverse events is not negligible, and long-term surveillance is mandatory. Most young athletes can return to an unrestrained lifestyle.Peer reviewe

Anomalous aortic origin of coronary arteries : Early results on clinical management from an international multicenter study

Background: Anomalous aortic origin of coronary arteries (AAOCA) is a rare abnormality, whose optimal management is still undefined. We describe early outcomes in patients treated with different management strategies. Methods: This is a retrospective clinicalmulticenter study including patients with AAOCA, undergoing or not surgical treatment. Patients with isolated high coronary take off and associated major congenital heart disease were excluded. Preoperative, intraoperative, anatomical and postoperative data were retrieved from a common database. Results: Among 217 patients, 156 underwent Surgical repair (median age 39 years, IQR: 15-53), while 61 were Medical (median age 15 years, IQR: 8-52), inwhomAAOCA was incidentally diagnosed during screening or clinical evaluations. Surgical patients were more often symptomatic when compared to medical ones (87.2% vs 44.3%, p b 0.001). Coronary unroofing was the most frequent procedure (56.4%). Operative mortality was 1.3% (2 patients with preoperative severe heart failure). At a median follow up of 18 months (range 0.1-23 years), 89.9% of survivors are in NYHA Conclusions: Surgery for AAOCA is safe andwith low morbidity. When compared to Medical patients, who remain on exercise restriction and medical therapy, surgical patients have a benefit in terms of symptoms and return to normal life. Since the long term-risk of sudden cardiac death is still unknown, we currently recommend accurate long term surveillance in all patients with AAOCA. (C) 2019 The Authors. Published by Elsevier B.V.Peer reviewe

The Role of Aortopulmonary Collaterals After an Arterial Switch Operation: A Word of Caution

This report describes the case of a neonate with dextro-transposition of the great arteries and an intact ventricular septum who required postoperative extracorporeal membrane oxygenation support for an unexplained postoperative left ventricular dysfunction after an arterial switch operation. After surgery, a large aortopulmonary collateral suspected of causing overload to the left ventricle was diagnosed. Percutaneous embolization of the aortopulmonary collateral caused prompt improvement in patient's conditions and rapid weaning from mechanical ventilation support

Unusual case of anomalous origin of the left coronary artery from the distal right pulmonary artery.

A full-term born, female baby with prenatal diagnosis of aortic coarctation underwent successful coarctectomy at 8 days of life. However, despite full anti-congestive therapy, she showed failure to thrive (body weight, 3.5 kg; 25th percentile) and congestive heart failure. At 2 months of age, two-dimensional echocardiography revealed a progression of mitral regurgitation from mild to moderate, dilated left ventricle, and decreased left ventricular ejection fraction of 40%. Cardiac angiography revealed an anomalous origin of the left main coronary artery from the distal right pulmonary artery, since only the right coronary artery was visualized (Fig 1), and the patient was scheduled for surgery. Through a midline sternotomy, the aorta was cannulated close to the origin of the innominate artery, and a single venous cannula was inserted in the right atrium. On moderately hypothermic (32\ub0C) cardiopulmonary bypass, we identified the left coronary artery, originating together with the seno-atrial nodal artery, from the right pulmonary artery, next to the hilar portion (Fig 2;DtAo = distal aorta; LCa = left coronary artery; Pa = pulmonary artery; PrAo = proximal aorta; RA = right atrium; RV = right ventricle; S-ANa = senoatrial nodal artery; SVC = superior vena cava). In Figure 2, it is valuable to note the anomalous origin of the left coronary artery and of the senoatrial node artery from the distal right pulmonary artery. After delicate dissection of the right pulmonary artery, the aorta was cross clamped close to the aortic cannula, and a cold cardioplegic cardiac arrest was obtained. After the aorta was completely transected, the left coronary ostium was identified through the lumen of the right pulmonary artery and was then harvested with a large button of the right pulmonary arterial wall (Fig 3;DtAO = distal aorta; LCa = left coronary artery; Pa = pulmonary artery; PrAO = proximal aorta; RA = right atrium; RV = right ventricle; S-ANa = seno-atrial nodal artery; SVC = superior vena cava). Note the coronary button of the anomalous left coronary artery detached from the distal right pulmonary artery. The coronary button was then re-implanted directly, with a trap door technique, using a continuous 8-0 polypropylene suture anastomosis to the left lateral wall of the ascending aorta, avoiding compression or kinking from the right pulmonary branch (Fig 4;Ao = aorta; LCa = left coronary artery; Pa = pulmonary artery; RA = right atrium; RPa = right pulmonary artery; RV = right ventricle; SVC = superior vena cava). Note the reimplanted left coronary artery on the neo-ascending aorta. Eventually, the aortic ends were directly anastomosed with a continuous 7.0 polypropylene suture. After the aortic cross clamp was released on the beating heart, the right pulmonary wall was reconstructed with autologous pericardium. Despite limited cross-clamp time (61 minutes), the patient could not be weaned off cardiopulmonary bypass and required left ventricular assist device (Bio-Medicus; Medtronic Inc, Eden Prairie, MN) for 48 hours postoperatively. After the chest was closed, the remaining postoperative stay was uneventful, and the patient was discharged home on postoperative day 8 on oral digoxin and furosemide. At her 6-month follow-up, an echocardiogram showed a normalized left ventricular function ejection fraction of 70%, with trivial mitral regurgitation

Pearls, pitfalls, and surgical indications of the Intuity TM heart valve: A rapid deployment bioprosthesis. A systematic review of the literature

ObjectivesTo highlight short- and long-term clinical outcomes of the Intuity TM rapid deployment prosthesis for surgical aortic valve replacement. MethodsWe reviewed on PubMed/MEDLINE, Embase, SciELO, LILACS, CCTR/CENTRAL, and Google Scholar for clinical trials, retrospective clinical studies, meta-analysis, and gray literature. ResultsFourty-five clinical studies with 12.714 patients were included in the analysis. Thirty-day mortality ranged from 3.8% for Intuity and 3.9% for transcatheter aortic valve replacement (TAVR). The incidence of paravalvular leak (PVL) (Intuity 0% and TAVR 2.17%), permanent pacemaker implantation (Intuity 11.11% and TAVR 12.5%), stroke (Intuity 2.2% and TAVR 2.6%), myocardial infarction (MI) (Intuity 0% and TAVR 1%), were all higher in the TAVR group. Compared to other sutured bioprosthesis (SB), mortality ranged from 0% to 3.9% for Intuity and 0%-6.9% for SB. Long-term cardiac mortality ranged from 0.9% to 1.55% for Intuity and 1.4%-3.3% for the Perceval valve. The incidence of PVL (Intuity 0.24%-0.7% and Perceval 0%-1%), endocarditis (Intuity 0.2%-0.7% and Perceval 1.6%-6.6%), stroke (Intuity 0.36%-1.4% and Perceval 0%-0.8%), MI (Intuity 0.07%-0.26%), and SVD (Intuity 0.12%-0.7% and Perceval 0%) were comparable. Compared to standard full sternotomy (SFS), minimally invasive surgery (MINV) mortality ranged from 0% to 4.3% for MINV and 0%-2.1% for SFS. Hospital costs outcomes ranged from $37,187-$44,368 for the Intuity, $69,389 for TAVR, and$13,543 for SB. Intuity short-term mortality ranged between 0.9% and 12.4% while long-term mortality ranged between 2.6% and 20%. ConclusionsThis manuscript provides a 360 degrees overview of the current rapid deployments, sutureless, and TAVR prosthesis

Surgery for anomalous aortic origin of coronary arteries: a multicentre study from the European Congenital Heart Surgeons Association

OBJECTIVES: We sought to describe early and late outcomes in a large surgical series of patients with anomalous aortic origin of coronary arteries.METHODS: We performed a retrospective multicentre study including surgical patients with anomalous aortic origin of coronary arteries since 1991. Patients with isolated high coronary takeoff and associated major congenital heart disease were excluded.RESULTS: We collected 156 surgical patients (median age 39.5 years, interquartile range 15-53) affected by anomalous right (67.9%), anomalous left (22.4%) and other anatomical abnormalities (9.6%). An interarterial course occurred in 86.5%, an intramural course in 62.8% and symptoms in 85.9%. The operations included coronary unroofing (56.4%), reimplantation (19.2%), coronary bypass graft (15.4%) and other (9.0%). Two patients with preoperative cardiac failure died postoperatively (1.3%). All survivors were discharged home in good clinical condition. At a median follow-up of 2 years (interquartile range 1-5, 88.5% complete), there were 3 deaths (2.2%), 9 reinterventions in 8 patients (5 interventional, 3 surgical); 91.2% are in New York Heart Association functional class <= II, but symptoms persisted in 14.2%; 48.1% of them returned to sport activity. On Kaplan-Meier analysis, event-free survival at follow-up was 74.6%. Morbidity was not significantly different among age classes, anatomical variants and types of surgical procedures. Furthermore, return to sport activity was significantly higher in younger patients who participated in sports preoperatively.CONCLUSIONS: Surgical repair of anomalous aortic origin of coronary arteries is effective and has few complications. Unroofing and coronary reimplantation are safe and are the most common procedures. The occurrence of late adverse events is not negligible, and long-term surveillance is mandatory. Most young athletes can return to an unrestrained lifestyle.Thoracic Surger