Tutorial
Cobrahead reimplantation of anomalous coronary arteries arising from the left coronary sinus
Cobrahead reimplantation is a novel technique that we have implemented to address an anomalous right coronary artery arising from the left coronary sinus, particularly in patients with a short intramural course. This technique requires complete mobilization of the anomalous vessel, detachment of the right coronary artery from its origin at the aorta and creation of a splay incision or ‘cobrahead’ within the proximal vessel. This cobrahead apparatus is then utilized to create a wide anastomosis during reimplantation of the vessel in the aorta, minimizing the risk of kinking or stenosis at this site. Our single-centre experience with this method has demonstrated excellent postoperative outcomes with long-term patency of the reimplanted coronary artery. These findings have been reaffirmed with longitudinal follow-up, which has demonstrated improvement in the instantaneous wave-free ratio, resolution of ischaemic symptoms and clearance for resumption of physical activity without restrictions. Furthermore, we have yet to encounter damage to the aortic valve apparatus utilizing this technique, reaffirming its utility in this patient population and its advantages relative to similar operative methods.
Anomalous aortic origin of the coronary arteries is one of the leading causes of myocardial ischaemia and sudden cardiac death in children and adolescents, affecting 0.2–1.2% of the population [1]. Operative intervention is recommended in patients who are symptomatic or exhibit diagnostic evidence of ischaemia, including aborted sudden cardiac death. Intervention is also recommended for asymptomatic individuals with an anomalous left coronary artery arising from the right coronary sinus or those with ventricular arrhythmias [2]. Patients with an anomalous right coronary arising from the left coronary sinus typically have an intramural segment and are often repaired using coronary unroofing. Complications from this technique may arise from the intramural course, coronary angulation within the aortic wall or fibrotic changes affecting the unroofed coronary artery [3,4]. Alternatively, our institution utilizes a novel repair technique in which the anomalous right coronary artery is translocated from the aortic wall and reimplanted to the correct sinus using a cobrahead anastomosis. We present our initial case series using this novel technique and demonstrate its reproducibility and feasibility in patients with short, intramural courses of the anomalous coronary artery.
1 – Patient Presentation (0:13)
Our patient is a 16-year-old male with no relevant past medical, surgical or family history who presented with episodes of chest pain and syncope. The patient did not have any abnormal electrocardiographic findings. The results of a transthoracic echocardiogram demonstrated normal biventricular function with a competent aortic valve. A computed tomographic scan showed an anomalous right coronary artery arising from the left coronary sinus with a short intramural course near the aortic valve commissure. Coronary catheterization demonstrated an instantaneous wave-free ratio (IFR) of 0.47. After multidisciplinary discussions, we proceeded with our cobrahead reimplantation of the anomalous right coronary artery.
2 - Median sternotomy and cannulation (1:19)
The aorta and right atrium were utilized as cannulation sites.
3 - Dissection of the anomalous right coronary artery (1:28)
The anomalous coronary artery was carefully dissected, allowing complete visualization of the vessel’s origin from the aorta. The dissection was continued along the entire course of the anomalous coronary artery. The site of reimplantation was marked prior to arrest in order to ensure appropriate location and orientation of the anastomosis.
4 - Aortic cross-clamp and cardioplegia administration (1:48)
The aortic cross-clamp was applied, and antegrade cold blood cardioplegia was used to achieve complete arrest of the heart.
5 - Detachment of the anomalous coronary artery (1:57)
A purse-string suture was placed at the takeoff of the anomalous right coronary artery. The right coronary artery was then transected at its base. Potts scissors were used to splay the proximal end of the vessel, resulting in the cobrahead appearance of the artery.
6 - Aortotomy (2:48)
An aortic punch was used to create an ostium in the aorta.
7 - Cobrahead reimplantation (3:05)
The anomalous coronary artery was reimplanted in the aorta using a wide, cobrahead anastomosis and 8-0 Prolene suture. The stump of the anomalous right coronary artery was then oversewn.
8 - Removal of the aortic cross-clamp and reperfusion of the heart (3:43)
The aortic cross-clamp was released, and the heart was re-perfused. The heart restarted in sinus rhythm. Excellent haemostasis was achieved. The reimplanted coronary artery was found to have an appropriate course without tension or kinking. An intraoperative echocardiogram demonstrated normal biventricular function.
Outcome
The patient’s postoperative course was unremarkable. He was discharged on post-operative day 3. On follow-up, he was asymptomatic with resolution of his syncope or chest pain and was cleared for physical activity. The echocardiogram demonstrated normal biventricular function and a competent aortic valve. The computed tomographic scan demonstrated a reimplanted right coronary artery with a good lie. IFR on catheterization demonstrated an IFR of 0.93.
On review of our experience, seven patients underwent reimplantation with the cobrahead technique. Median bypass and cross-clamp times were 75 and 37 minutes, respectively. Postoperatively, all patients had normal left ventricular and right ventricular function with no reported aortic valve regurgitation on the postoperative echocardiogram (Table 1). A comparison of the pre- and postoperative catheterizations (5/7, 71%) demonstrated an improvement in the IFR of 0.18. All patients reported symptomatic improvement and denied chest pain or syncope at the time of the last follow-up.
The cobrahead reimplantation technique resulted in the maintenance of aortic valve competency and improvement in IFR, including in those with a short intramural course or a slit-like coronary ostia. Postoperative imaging, IFR values and symptomatic improvement demonstrated that the cobrahead anastomosis facilitated wide-open patency of the reimplanted coronary artery. During this technique, complete distal mobilization of the anomalous coronary was necessary to reduce acute angulation or kinking of the coronary artery. The cobrahead reimplantation technique is a highly reproducible approach to addressing an anomalous right coronary artery and offers key advantages that may reduce complications seen in other approaches.
Table 1: Our series of seven patients demonstrates improvement in symptoms in the postoperative period as well as normal biventricular and aortic valve function.
|
|
Pre-op |
Post-op |
||||||
|
|
Age at surgery, years |
Symptoms |
IFR |
Anatomy |
Bypass/XC (min) |
Echo |
IFR |
Symptom resolution |
|
Patient 1 |
63 |
Chest pain |
N/A |
Short intramural segment |
76/50 |
Normal fxn No WM Abn No AR |
N/A |
Yes |
|
Patient 2 |
54 |
Chest pain, SOB |
N/A |
Interarterial course |
57/30 |
Normal fxn No WM Abn No AR |
N/A |
Yes |
|
Patient 3 |
16 |
Syncope |
0.47 |
Slit-like ostium |
66/35 |
Normal fxn No WM Abn No AR |
0.95 |
Yes |
|
Patient 4 |
16 |
Chest pain |
0.84 |
Short intramural segment |
85/63 |
Normal fxn No WM Abn No AR |
0.96 |
Yes |
|
Patient 5 |
17 |
Cardiac arrest |
0.84 |
Short intramural segment |
75/37 |
Normal fxn No WM Abn No AR |
0.89 |
Yes |
|
Patient 6 |
18 |
Chest pain |
0.87 |
Slit-like ostium |
105/57 |
Normal fxn No WM Abn No AR |
0.93 |
Yes |
|
Patient 7 |
19 |
Syncope |
0.71 |
Acute angulation of AAORCA |
72/28 |
Normal fxn No WM Abn No AR |
0.97 |
Yes |
AAORCA: anomalous aortic origin of a right coronary artery; AR: aortic regurgitation; fxn: function; IFR: instantaneous wave-free ratio; Post-op: postoperative; Pre-op: preoperative; SOB: shortness of breath; WM Abn: wall motion abnormality; XC: cross-clamp.
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PubMed Abstract | Publisher Full Text
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PubMed Abstract | Publisher Full Text
4. Mery CM, De Leon LE, Molossi S, Sexson-Tejtel SK, Agrawal H, Krishnamurthy R et al. Outcomes of surgical intervention for anomalous aortic origin of a coronary artery: A large contemporary prospective cohort study. J Thorac Cardiovasc Surg 2018;155:305–19.e4.
Authors
Nicholas A. Oh, Olivia McCloskey, Ahmad Munir, Tara Karamlou & Hani K. Najm
Affiliation
Pediatric and Congenital Heart Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
Corresponding Author
Nicholas Oh
Department of Thoracic and Cardiovascular Surgery
Cleveland Clinic
Cleveland
OH
USA
Email: ohn2@ccf.org
© The Author 2025. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
