Redo Operation of Coronary Artery Ostia Aneurysm

Repairing a right coronary artery (RCA) ostial aneurysm in a patient with a prior Bentall operation presents unique technical challenges due to adhesions, altered root anatomy, and the presence of a composite valve-graft conduit. After meticulous resternotomy and careful dissection to avoid injury to the right ventricle or patent grafts, cardiopulmonary bypass is established - often via peripheral cannulation if mediastinal adhesions are dense. Myocardial protection strategy must consider prior coronary reimplantation. The aneurysmal RCA button is carefully mobilized from the Dacron graft, with attention to preserving distal coronary flow. Depending on the extent of tissue degeneration, repair options include resection of the aneurysmal segment with direct reimplantation into the composite graft, interposition grafting using a short Dacron or saphenous vein segment, or coronary artery bypass grafting (e.g., SVG to distal RCA) with oversewing of the native ostium if the tissue is friable. Reinforcement with pledgeted sutures is essential to prevent recurrence or bleeding. In redo settings, operative planning must also account for potential pseudoaneurysm, infection, and the need for root revision. Durable repair hinges on achieving tension-free anastomosis, secure hemostasis, and preservation of right ventricular perfusion.