Surgical correction of anomalous origin of the coronary artery: a scoping review on clinical outcomes, techniques, and knowledge gaps

Background Anomalous coronary artery origin(AOCA) is a rare congenital condition linked to ischemia and sudden death, especially in young athletes. The highest risk is associated with an anomalous left coronary artery from the aorta(AAOLCA) with an interarterial course. Surgery is recommended for symptomatic cases, with unroofing as the preferred technique. However, management of asymptomatic patients remains uncertain and requires individual risk assessment. Objective To assess clinical outcomes of corrective surgery and identify knowledge gaps. Methods A scoping review following PRISMA-ScR analyzed 15 cohort studies since 2010, including 1,286 surgical and 351 conservatively managed patients. The review evaluated diagnosis, surgical techniques, complications, mortality, survival, cardiovascular events, and quality of life. Studies without quantitative data were excluded. Results Diagnosis: AOCA of the right coronary artery (AAORCA) was most common (60%), followed by AAOLCA (25%). Bilateral cases accounted for 5%. Surgical Techniques: Unroofing was performed in 74.5%, coronary reimplantation in 13.2%, and coronary artery bypass grafting (CABG) in 7.2% of complex cases. Complications: Reintervention occurred in 6.4%, more frequent after reimplantation and CABG. Arrhythmias (5–10%) and residual stenosis (4–9%) were common. Mortality: Surgical mortality was 1.2%, lowest for unroofing (<1%) and highest for CABG (3.5%). Sudden death occurred in the conservative group. Follow-up & Survival: Mean follow-up was 3.5 years, with 98.8% survival. Surgery reduced sudden death risk. Cardiovascular Events: Occurred in 6%, more common in reimplantation and CABG. Quality of Life: After surgery, 72.5% were asymptomatic, and 48.1% resumed sports, whereas the conservative group had limitations. Conclusion Surgical outcomes depend on technique and anomaly type. Unroofing (74.5%) was most common, particularly for AAORCA (60.0%) and AAOLCA (25.0%), with good safety. It decompresses the intramural segment, improving coronary flow and reducing ischemic symptoms in over 90% of cases. Reimplantation (13.2%) had higher reintervention rates (8.2%) but is crucial for anatomical correction in cases with ostial narrowing. CABG (7.2%) had the highest mortality (3.5%) but remains an option in patients with concurrent atherosclerotic disease. Conservative treatment (21.4%) remained an option but did not eliminate sudden death risk. Surgery improved quality of life, with 72.5% asymptomatic and 48.1% returning to sports. Key knowledge gaps include surgical criteria for asymptomatic cases, pediatric screening, follow-up standardization, and long-term coronary function post-surgery. Additional challenges involve determining the ideal age for intervention, assessing surgical durability beyond 10 years, and understanding the impact of physical activity restrictions postoperatively. Further research with extended follow-up is needed to refine guidelines.