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A 59-year-old woman presented with right heart enlargement. Computed
tomography angiography revealed a 22mm right coronary artery (RCA)
draining into an enlarged coronary sinus (CS) (Figures 1-3) .
Cardiac catheterization revealed a Qp:Qs of 2.0. We proceeded with
surgery1. Intraoperatively, a thrill was palpable upon
the RCA and right atrium (RA) (Figure 4) . Circumferential
control around the RCA origin was achieved as it emerged from the right
sinus of Valsalva into the right ventricular fat. The distal ascending
aorta and vena cavae were cannulated. Cardiopulmonary bypass was
initiated. The aorta was cross-clamped and a bulldog clamp was placed on
the proximal RCA. Del Nido cardioplegia was delivered into the ascending
aorta and electrical arrest achieved. Tourniquets were secured around
the vena cavae. The distal RCA was opened just proximal to its junction
with the CS. An opening into the CS was confirmed by passing a probe
from the RCA into the CS, and closed with a bovine pericardium patch
using continuous 6-0 Prolene. The right coronary arteriotomy was closed
with two layers of 6-0 Prolene. An end-to-side anastomosis of a
saphenous vein graft to the posterior descending artery (PDA) was
performed using continuous 7-0 Prolene. The RA was opened. Cardioplegia
was infused through the vein graft into the PDA, and the CS was
inspected to confirm no flow into the CS. The RA was closed. A
side-to-side anastomosis of the vein graft to the right ventricular
marginal artery was performed using a double diamond technique and
continuous 7-0 Prolene. The RCA origin was triply ligated using two
separate 4-0 Prolene sutures with a 2-0 silk ligature in between. A
single proximal anastomosis to the ascending aorta was performed using a
4.0mm aortic punch and continuous 6-0 Prolene. At the procedure’s close,
mixed venous oxygen saturation was 76%. Six months later the patient
was doing well.