Journal of Pediatric Cardiology and Cardiac Surgery 8(2): 77‒81 (2024)

Case Report

Reimplantation for Anomalous Aortic Originof Right Coronary Artery in the Elderly
Kazuki Tanimoto, MD, Masayuki Sakaki, MD, PhD, Tatsuya Oyama, MD,
Hiroki Mizoguchi, MD, and Nobuo Sakagoshi, MD, PhD
Department of Cardiovascular Surgery, Kinan Hospital, Wakayama, Japan

Anomalous aortic origin of the right coronary artery (AAORCA) is a rare congenital anomaly. It is even rarer inthe elderly, and there is ongoing controversy regarding techniques for surgical intervention. We describe a case ofAAORCA that was successfully treated using a reimplantation technique. A 65-year-old female with a history ofexercise-related angina was referred to our hospital. Enhanced computed tomography (CT) revealed AAORCA.
Ischemia was detected on electrocardiogram exercise testing, although myocardial perfusion scintigraphy had
failed to show it; thus, surgical intervention was recommended. We applied a reimplantation technique, because
the right coronary artery (RCA) was not hypoplastic but its proximal course was interarterial with a slit-likeostium. We transected the RCA beyond the intramural portion and closed the residual stump proximally. Anaortic wall was punched out higher in the right facing sinus of Valsalva to create a neo-ostium. The RCA was spatulated on the inferior side and anastomosed to the neo-ostium. The patientʼs postoperative course was uneventful. Postoperative enhanced CT showed neither stenosis nor kinking of the reimplanted vessel. The patient has
been asymptomatic for more than 2 years since the operation. The reimplantation technique was useful for
AAORCA with a slit-like ostium and an interarterial course. Its medium- to long-term outcomes are reported tobe satisfactory. Therefore, the reimplantation technique could easily be applied to similar cases.

Keywords: anomalous aortic origin of right coronary artery, coronary artery anomaly, reimplantation
technique, unroofing technique, coronary artery bypass grafting

Introduction
Anomalous aortic origin of the right coronary artery(AAORCA) is a rare congenital anomaly that may cause
sudden cardiac death, especially in young athletes.1) It
is quite rare to find the malformation in the elderly. The2018 Adult Congenital Heart Disease (ACHD) Guideline2) states that surgery is recommended for AAORCA
in patients with symptoms, or diagnostic evidence
consistent with coronary ischemia, attributable to theanomalous coronary artery. As for surgical intervention,
there is ongoing controversy over the techniques, especially in the elderly. Here we describe a case of an elderly
patient whose evaluation of episodic chest pain revealed

AAORCA. Her right coronary artery (RCA) had aninterarterial course with a slit-like ostium and it was
successfully treated using a reimplantation technique.

Case Report
A 65-year-old woman with a history of exercise-related
angina was referred to our hospital. She had no historyof syncope or ventricular arrhythmia, and no coronary
risk factors. The electrocardiogram at rest was within
normal limits, and echocardiogram showed no left
ventricular asynergy. However, laboratory data indicated elevated troponin I (74.5 pg/mL). She underwent
coronary angiography, which revealed AAORCA. Coronary 3D computed tomography (CT) showed the RCA

Received: May 10, 2023; Accepted: October 12, 2023
J-STAGE Advance Published Online: July 4, 2024
Corresponding author: Kazuki Tanimoto, MD, Department of Cardiovascular Surgery, Kinan Hospital, 46‒70 Shinjo-cho, Tanabe-city,Wakayama 646‒8588, Japan
E-mail: k-tanimoto@surg1.med.osaka-u.ac.jp
Kazuki Tanimoto ( https://orcid.org/0000-0002-5299-8867)
doi: 10.24509/jpccs.23-009© 2024 Japanese Society of Pediatric Cardiology and Cardiac Surgery
This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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departing independently from the left coronary sinus ofValsalva and passing between the ascending aorta andthe pulmonary trunk (the so-called interarterial course)(Fig. 1A, B).
Myocardial perfusion scintigraphy failed to exhibit
ischemia; nonetheless, electrocardiogram exercise testing revealed ST depression in leads II, III, and aVF. Thus,
we recommended surgical intervention based on theguideline.2)
Through a median sternotomy, the AAORCA wasidentified (Fig. 2A); using a harmonic scalpel, we dis-sected the proximal portion of the RCA just distal tothe intramural portion for 2 cm, sparing the proximalbranches. The superior aspect of the RCA was marked
to prevent distortion. Cardiopulmonary bypass wasestablished by cannulation to the ascending aorta andthe right atrium. The left ventricular venting tube wasinserted via the right upper pulmonary vein. The initialcardioplegia was infused antegradely from the aorticroot. A transverse aortotomy was performed 15 mmabove the sino-tubular junction. We confirmed thatboth the left coronary artery and the RCA originatedFig. 1 Enhanced computed tomography before the operation(A) Axial view (viewing from below) showing that the right coronary artery (RCA) arises from the left coronary sinus ofValsalva and passes between the aorta (Ao) and the pulmonary artery (PA). (B) Cranial view (from above) of 3D computed
tomography showing that the course of the RCA is interarterial and that the interarterial portion is ﬂattened. Ao, aorta; PA,pulmonary artery.

Fig. 2 Intraoperative images(A) The anomalous origin and the course of the right coronary artery (RCA). Arrows indicate the anomalous aortic origin of
the right coronary artery (AAORCA). The dashed circle shows the precise site of a neo-ostium. (B) Ostia of the left and theright coronary arteries (LCA and RCA) originating from the left facing sinus of Valsalva. The ostium of the RCA was slit-like.
Ao, aorta; LCA, left coronary artery; LCC, left coronary cusp; RCA, right coronary artery; RCC, right coronary cusp.

J Pediatr Cardiol Card Surg Vol. 8, No. 2 (2024)

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Fig. 3 Schematic illustration of the operation
LCA, left coronary artery; LCC, left coronary cusp; NCC, non-coronary cusp; PA, pulmonary artery; RCC, right coronary cusp.

Fig. 4 Enhanced computed tomography (CT) after
the operation
Cranial view (from above) of 3D CT showing that theright coronary artery (RCA) has been reimplanted tothe neo-ostium. The RCA had neither stenosis norkinking. The arrow indicates a coronary locator.

independently from the left coronary sinus of Valsalva,
and that the RCA ostium was slit-like (Fig. 2B). We transected the RCA adjacent to the intramural portion. The
residual proximal stump was 10 mm long. The stump
was clipped, and the amputated end was oversewn
with 7-0 polypropylene. The wall of the very proximal
ascending aorta, just above the sino-tubular junction on
the right facing sinus aspect, was punched out to create
a neo-ostium. The RCA was spatulated for 4 mm on theinferior side and was anastomosed to the neo-ostium
using running 6-0 polypropylene beginning at the heel.

The aortotomy was closed in two layers. After infusionof warm cardioplegia, the aorta was unclamped. Electrocardiogram showed normal sinus rhythm with nosignificant ST-T change. The RCA flow was measured
intraoperatively as 54 mL/min using doppler ultrasound.
A schematic illustration of the surgery is shown in Fig.
3A, B.
The patientʼs postoperative course was uneventful.
She started to take aspirin on postoperative day 1. The
postoperative coronary 3D CT taken before discharge
showed neither stenosis nor kinking of the reconstructed RCA (Fig. 4), and the patient was discharged
on postoperative day 13. She has been asymptomatic formore than 2 years since the operation.

Discussion
Anomalous aortic origin of the coronary artery(AAOCA) was first described by White and Edwardsin 1948.3) The prevalence of AAORCA is reported to be
0.107% to 0.2%.4, 5) The pathomechanism of high-risk
anatomic features during physical exercise includes a)kinking of the anomalous vessel with an acute-angled
take-off, b) lateral compression caused by the aorta onto
the intramural segment, c) intermittent closure of aslit-like orifice, and d) compression onto the interarterial
portion by the aorta and the pulmonary artery.6) In ourpatient, c) and d) were the main causes of ischemia.
The 2018 ACHD Guideline2) states that, for anomalous aortic origin of the left coronary artery from theright sinus, surgery is reasonable even in the absence© 2024 Japanese Society of Pediatric Cardiology and Cardiac Surgery

80of symptoms or ischemia (class IIa). For AAORCA, on
the other hand, surgery is recommended only in thepresence of symptoms or diagnostic evidence consistent
with coronary ischemia attributable to the anomalous
coronary artery (class I). Otherwise, surgery is reasonable in the setting of ventricular arrhythmias (class IIa).
In our patient, we were initially unable to detect ischemia using myocardial perfusion scintigraphy. But thecardiologist decided to check using electrocardiogram
exercise testing, despite its risk of ventricular arrhythmia, after obtaining informed consent. This was because
the patientʼs chief complaint, exercise-related angina,
seemed to be strongly related to this anomaly.
Several techniques may be used for surgical repair ofAAORCA, including coronary artery bypass grafting(CABG), unroofing, reimplantation, and pulmonary
arterial translocation.7, 8) CABG is a well-establishedtechnique that can be done without cardiopulmonary
bypass. With this procedure, however, there is a concern regarding competitive flow at rest, and accordingly
long-term patency. A short bypass using the great saphenous vein (e.g., aorta‒great saphenous vein‒RCA in thiscase) may have better patency. Moreover, myocardial
infarction would not occur immediately, even if thebypass became non-patent.
The unroofing technique is the surgical option mostwidely used for intramural AAOCA.9) As discussed
above, however, the probable pathomechanisms ofischemia in our patient were intermittent closure of theslit-like orifice and compression onto the interarterial
portion by the aorta and the pulmonary artery. The
unroofing technique should be effective for the type ofa slit-like orifice, but would not be for the interarterialcircumstance.
In contrast, reimplantation techniques can be applied
to either intramural or interarterial AAOCA, and they
seem to have good medium- to long-term results regarding symptom-free survival.10‒12) Law et al. reported
16 cases of AAORCA repaired by reimplantation.10)
Surgical reimplantation was successful in 15 patients(94%) without operative mortality, and all patients weresymptom-free after surgery. Cubero et al. reported 13
cases of AAORCA11); all patients are asymptomatic andhave returned to exercise without limitations. Bonilla-Ramirez et al. reported 16 cases of AAOCA12); onepatient underwent CABG after reimplantation becauseof persistent postoperative ischemic changes, while 15
J Pediatr Cardiol Card Surg Vol. 8, No. 2 (2024)

patients (94%) were released to unrestricted exercise
activities. Also, a recent report has shown that thecommissural manipulation associated with unroofing
technique may leads to the future aortic insufficiency,13)which may support the choice of the reimplantation
technique in the present patient.
Because reimplantation has a potential risk of stretching, kinking, distortion, or stenosis at the anastomosis
site, it is difficult to use in patients with a small coronary
artery; for example, pediatric patients or patients with ahypoplastic RCA. In our case, we chose reimplantation
because the RCA was not hypoplastic but was interarterial with a slit-like ostium. The patient was 65 years old.
Thus, we expected a good long-term result.
Pulmonary arterial translocation may be an alternative technique in selected cases with an anomalouscourse of the coronary artery as a part of complex coronary arterial anatomy; in such an occasion, the risk ofcoronary reimplantation may outweigh the anticipatedbenefits. In particular, surgical options may be limited inyounger patients.14)
There are some knacks related to the reimplantation
techniques, such as 1) mobilization of the RCA sparing
the proximal branches of the RCA, 2) reimplantationof the RCA higher in the right facing sinus or at thevery proximal ascending aorta, and 3) confirmation ofcorrect positioning of the neo-ostium about the aortic
valve commissures.15) We employed the reimplantation
technique for the first time; still, the outcome seemed
excellent based on adequate knowledge for theseapproaches obtained prior to surgery. In this sense, thereimplantation technique can be reproducibly applied tosimilar cases.
In conclusion, we report a case of reimplantationof the RCA in an elderly patient with AAORCA. The
surgical technique used is to be selected according tothe patientʼs age, morphology of the coronary arteries,and other comorbidities. The reimplantation technique
is useful and would be of a surgical option of choice forsimilar cases.
Conﬂicts of Interest
The authors declared no potential conflicts of interest
with respect to the research, authorship, and/or publicationof this article.

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Ethical Considerations
Informed consent was obtained from the patient to publish a case report.
Author Contribution
Kazuki Tanimoto drafted the original manuscript. Kazuki
Tanimoto, Masayuki Sakaki, Tatsuya Oyama and Hiroki
Mizoguchi treated the patient. Kazuki Tanimoto andTatsuya Oyama contributed to the acquisition of clinicaldata and imaging. Nobuo Sakagoshi supervised the conductof this case. All authors reviewed the manuscript draftand revised. All authors approved the final version of themanuscript to be published.

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