Coronary translocation during aortic root replacement with the pulmonary autograft: complications and their...

Aortic root replacement with the pulmonary autograft has become an alternative to replacement of the diseased aortic valve with mechanical or biological prostheses. Due to greater technical complexity of the operation, complications with autograft root replacement (ARR) may be more common. In particular, a higher prevalence of coronary complications has been suggested.

In order to assess the prevalence, cause and management of coronary complications after ARR, results with 26 consecutive operations were reviewed and compared with previously published series. Between July 1994 and Apri 1997, 22 males and four females (mean age 26 +/- 8 years; range: 11 to 36 years) underwent aortic root (n = 22) or valve replacement (n = 4) with a pulmonary autograft for regurgitation (n = 14), stenosis (n = 4) or both (n = 8). Associated lesions were present in 10 (38%) patients, including three cases of major coronary artery anomalies such as origin of the circumflex from the right coronary sinus, high origin of the right coronary, aneurysmal and calcified right and left main coronaries, both in one patient.

There were no early deaths. Major complications occurred in six patients; re-exploration for bleeding was required in three (11%) and partial take down of repair for coronary complications in three (11%), all with preoperative coronary anomalies. Two of the latter patients presented with intraoperative right ventricular ischemia due to kinking of the right coronary (corrected by re-implantation at a higher level), and one had intraoperative hemorrhage due to rupture of a calcified left main coronary, which required transection of the pulmonary homograft above the valve to expose the tear. Recovery was prompt in all patients (mean ICU stay 35 +/- 28 h) with no metabolic or electrocardiographic evidence of ischemia. Echocardiography at discharge showed satisfactory biventricular kinetics in all; mild regurgitation of the autograft was found in two (8%) who had undergone subcoronary implant, and absent or trivial in 22 (92%). One patient died suddenly 13 months after ARR; hence actuarial survival rate was 100% and 96% at 12 and 24 months, respectively. At mean follow up of 15 +/- 11 months (range 1 to 32 months), all patients are in NYHA class I and have returned to school or prior employment.

Complications with coronary artery translocation during ARR may be a definite risk, particularly in the presence of coronary anomalies. Prompt recognition and an aggressive intraoperative approach, including partial take down of the repair, may limit the morbidity of this complex surgical procedure.