Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3735_Библиотеки_им_академика_М_И_Перельмана

intensive care unit [24, 25]. Serious complica­tions may also occur at a considerable distance after surgery [26, 27].

In patients undergoing aortic valve replace­ment, complications related to compression of the abnormal interarterial vessel have been described and can be extremely severe [41, 42]. A strategy to manage this condition is mandatory in these cases. If the ACA has an intramural tract, unroong has been the most widely used tech­nique [43, 44] (Fig.20.2– insert). In their review, Davies etal. [43] described 36 patients with an ACA with an interarterial course. In 94% of the cases, the anomalous coronary artery also had an intramural course. Six patients (16.7%) also underwent associated procedures (replacement/ repair of the aortic valve 4; mitral valve 1; or ascending aorta 1). Interestingly, 61% (22 patients) underwent unroong, preferably when the anomaly involved the right coronary artery. The main risk of unroong is distortion of the commissure between the right and left cusps, resulting in aortic valve failure. Obviously, in patients undergoing aortic valve replacement, this is not the case [15]. On the contrary, in patients in whom a valve repair is planned, the course of the intramural tract must be evaluated. If it lies above the commissure, the risk of distor­tion is minimal. If, however, it lies below the commissure, there are two possibilities: detach the commissure, unroof the intramural segment, and resuspend the commissure; or create a new ostium.

Apart from anecdotal cases [53] in which cor­rection of the anomalous coronary artery was not performed, complications have occurred during weaning from the extracorporeal circulation or in the intensive care unit, with the need to perform an urgent aortocoronary bypass [41, 42]. For this reason, this approach should be discouraged.

is essential [55, 56]. Indeed, coronarography alone may not be sufcient to clarify the origin and course of a coronary artery with high take-off [55–57]. When a high origin of the ACA is sus­pected or established, based on its course, it may be necessary to perform a right-sided transverse [22, 56] or vertical aortotomy [58]. When there is an intramural course, unroong or reimplantation is not feasible, because there is a risk of exces­sively weakening the aortic wall and having to replace it [55]. Conversely, when there is no intramural course, prior isolation of the coronary artery has been proposed [22].

packing of the proximal subannular suture line of the aortic graft at the ventricular-aortic junction (in case of reimplantation technique), and to pre­vent kinking after reimplantation [29, 60, 64, 65]. When preparation of the vessel is impossible or the vessel is damaged, it has been recommended to ligate the anomalous circumex artery proxi­mally and proceed to aortocoronary bypass [65]. Although they had successfully isolated the anomalous coronary artery from the root, Akiel etal. still packaged a graft with the left internal mammary artery on the obtuse marginal branch, but this occluded early due to competitive ow [64]. Systematic closure of the native anomalous coronary vessel has been proposed [60]. The ACA is reimplanted alone or together with the right coronary artery in a composite button in the right sinus of Valsalva [64, 66] or in the tubular portion of the vascular graft [65]. In Bentall’s case, too, mobilization of an anomalous retroaor­tic circumex artery is essential [63].

which remains silent until adulthood, could cre­ate numerous problems following aortic/mitral valve or aortic surgery. In this sense, accurate preoperative imaging and a multidisciplinary approach by the Heart Team are absolutely necessary.