What is the Optimal Surgical Technique for Anomalous Aortic Origin of a Coronary Artery?

Anomalous aortic origin of a coronary artery (AAOCA) is associated with an increased risk of sudden cardiac death. Multiple surgical techniques have been developed to treat this anomaly. The optimal surgical technique to treat AAOCA is unclear but varies depending on the specific patient anatomy. We discuss 3 different techniques: unroofing of an intramural segment, coronary transection and reimplantation, and creation of a neo-ostium. Unroofing is optimal when the anomalous coronary has a long intramural segment that travels above the aortic valve. Creation of a neo-ostium by partially unroofing the coronary at the appropriate sinus should be considered if there is a long intramural segment that travels below the aortic valve. Coronary reimplantation is optimal if the intramural segment travels below the aortic valve but is not long enough for creation of a neo-ostium, or if there is a short or nonexistent intramural segment. Surgical technique should be individualized based on patient anatomy, and all potential anatomic culprits addressed.