Anomalous aortic origin of coronary arteries: 'anatomical' surgical repair.

Anomalous aortic origin of coronary arteries (left coronary from right sinus or right coronary from left sinus) is a rare congenital defect, which carries a high risk of sudden cardiac death. The risk is particularly high when the interarterial course between the great arteries has an intramural segment, or is hypoplastic/stenotic, or has an abnormal orifice. Various surgical techniques have been used, including coronary artery bypass grafting, pulmonary artery translocation, partial or complete unroofing of the intramural course and patch enlargement of the interarterial course. We favour 'anatomical' repair that creates an enlarged neo-ostium into the appropriate sinus, eliminates completely the intramural segment and restores a normal angle of take-off. Reimplantation of the anomalous coronary artery may be indicated in variants without an intramural course. Surgical correction is mandatory for symptomatic and asymptomatic patients with evidence of myocardial ischaemia under stress; it is recommended in asymptomatic patients with high-risk variants (anomalous left coronary artery with the intramural course), particularly in young patients with strenuous activities.