In this video, Mayo Clinic pediatric cardiovascular surgeon Elizabeth H. Stephens, M.D., Ph.D., discusses anomalous coronary artery unroofing, a surgical treatment for anomalous aortic origin of the coronary artery (AAOCA). In AAOCA, one of the coronary arteries arises from the aorta in an abnormal position. This may be found incidentally when a patient undergoes a CT scan for another reason, or it may be encountered during a work-up for chest pain or other symptoms. While there is a range of presentations and consequences of the anomaly, in some cases it can cause ischemia and even sudden death.
[MUSIC PLAYING] ELIZABETH STEPHENS: My name is Elizabeth Stephens. I'm a pediatric and congenital cardiac surgeon at Mayo Clinic. Today, I'll be covering repair of total anomalous pulmonary venous return. Total anomalous pulmonary venous return is when the pulmonary veins do not connect correctly to the left atrium. Rather, these veins collect in a chamber behind the left atrium. Shown in this diagram, the four red arrows on either side show the oxygenated blood coming back from the lungs. You can see they are trying to get back to the left atrium, but they are blocked where the red dashed line is, so they go up the vertical vein and around to join the blue blood on the right side of the heart. The highlighted yellow shows the hole in the atrium that allows blood into the left atrium so that the left heart has some blood to pump to the body. There are three main types of TAPVR, depending on where the vertical vein connects-- supracardiac if it connects above the heart, shown in this diagram, infracardiac if it connects below the heart, and intracardiac. If and when the blood flow of these pulmonary veins is obstructed, these babies get quite sick. In this video, we demonstrate the surgical technique for repair. This is a 2.4-kilo two-day-old. Here, the chest is open. We proceed to put the cannulas in place to put the baby on the heart-lung machine. And here, the blood is starting to flow to the machine. You can appreciate how tiny the heart is. Now, we are tying off the patent ductus arteriosus, which is a shunt in utero that isn't needed once the baby is born. Now, we are flipping the heart into the right chest to access the back side of the heart where this confluence of the pulmonary veins is. This diagram shows the anatomy with the common chamber containing the veins behind the left atrium. We are dissecting out this pulmonary-venous confluence. [MUSIC PLAYING] Now we are entering the confluence. You can see on either side the pulmonary veins entering the confluence. We are dissecting out further to create a large-enough opening for the anastomosis. [MUSIC PLAYING] This diagram depicts the opening in the chamber of the pulmonary veins, as well as that in the left atrium. [MUSIC PLAYING] Here, we are opening the left atrium, and you can see the tip of a catheter. Now, we are suturing the pulmonary-venous confluence to the left atrium. This will allow the blood to return back to the left side of the heart normally. We use very fine suture. [MUSIC PLAYING] The vertical vein will then be tied off because that vein is no longer needed to get the blood back to the heart. This diagram shows the final results of the anastomosis. Now, we are opening the right atrium, and you can see a small hole between the right and left sides of the heart-- patent foramen ovale. We are closing this. [MUSIC PLAYING] Now, we are closing the right atrium, and we start to bring the baby off the heart-lung machine. [MUSIC PLAYING] Shown here is the final result as the heart is starting to beat again. [MUSIC PLAYING]