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Ann Thorac Surg 1996;62:1886-1887
© 1996 The Society of Thoracic Surgeons

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Correspondence

Anomalous Origin of the Right Coronary Artery as a Risk Factor in Aortic Valve Surgery

First Department of Surgery, Kumamoto University School of Medicine, 1-1-1 Honjo, Kumamoto City, Kumamoto 860, Japan

To the Editor:

We read with interest the article entitled "Acute Right Ventricular Failure During Aortic Valvular Operation Due to Mechanical Problem in the Right Coronary Artery" by Salerno and associates in the February 1996 issue of The Annals [1]. They reported 9 patients suffered acute right ventricular failure during aortic valve operations. Recently, we encountered a similar acute complication in the immediate postoperative period. A 54-year-old man presented with palpitation and dyspnea on exertion, and an echocardiogram revealed severe aortic regurgitation. At operation, a bicuspid aortic valve was found and replaced with a mechanical prosthesis. Weaning from cardiopulmonary bypass was difficult because right ventricular contractility was poor, and there were several episodes of ventricular fibrillation. The patient was weaned using adjunctive intraaortic balloon pumping and venoarterial bypass. The postoperative electrocardiogram showed elevation of the ST segments and new Q waves in leads II, III, and aVf. The maximum serum creatine kinase MB fraction concentration was 471 IU/L. The patient died on the 23rd postoperative day. An autopsy revealed massive necrosis of the right ventricle and an anomalous right coronary artery (RCA), originating from the left sinus of Valsalva. The proximal RCA crossed the anterior wall of the aorta before entering the right atrioventricular groove. One stitch of the continuous running suture that had closed the aortic root had been placed around the RCA producing acute obstruction.

Congenital bicuspid aortic valve is a cause of aortic regurgitation in 14% of patients [2]. This anomaly may be associated with other anomalies of the coronary arteries [3–5]. Preoperative aortography and coronary angiography would have detected the vascular anomalies. During aortic valve operations, cardioplegic solution is infused directly into the ostia of both coronary arteries. The ostium of the left coronary artery is seen easily, but the ostium of the RCA can be difficult to visualize directly. In such circumstances, the cannula may not be placed correctly in the RCA. If the coronary perfusion pressure does not increase or the solution does not leak, the error may go unnoticed as occurred in this case.

When unexpected right heart failure occurs during an aortic valvular operation, Salerno and associates [1] recommend coronary artery bypass grafting to the RCA. This might be a better procedure than mechanical support with balloon pumping and venoarterial bypass. Air embolization and trauma to the right coronary ostium may also cause acute right heart failure [1]. Although the RCA arises from the left aortic sinus in only 0.1% to 0.2% of the population [3–5], the failure of cardiac surgeons to be aware of this infrequent anatomic variant may have fatal consequences.

References

1. Salerno TA, Bergsland J, Calafiore AM, Cordell AR, Kon ND, Bhayana JN. Acute right ventricular failure during aortic valvular operation due to mechanical problem in the right coronary artery. Ann Thorac Surg 1996;61:706–7.[Abstract/Free Full Text]
2. Kirklin JW, Barratt-Boyes BG. Aortic valve disease. In: Kirklin JW, Barratt-Boyes BG, eds. Cardiac surgery. 2nd ed. New York: Churchill Livingstone, 1993:491–571.
3. Roberts WC. Major anomalies of coronary artery origin seen in adulthood. Am Heart J 1986;111:941–63.[Medline]
4. Kimbiris D, Iskandrian A, Segal BL, Bemis CE. Anomalous aortic origin of coronary arteries. Circulation 1978;58:606–15.[Free Full Text]
5. Chaitman BR, Lesperance J, Saltiel J, Bourassa MG. Clinical, angiographic, and hemodynamic findings in patients with anomalous origin of the coronary arteries. Circulation 1976;53:122–31.[Abstract/Free Full Text]

Reply

Department of Surgery, State University of New York at Buffalo, School of Medicine and Biomedical Sciences, The Buffalo General Hospital, 100 High St, Buffalo, Ny 14203

To the Editor:

Doctors Utoh and Goto present yet another cause of acute right ventricular failure during aortic valve operations, namely, anomalous origin of the right coronary artery (RCA). In this case, the RCA arose from the left sinus of Valsalva, crossing the anterior wall of the aorta before entering the atrioventricular groove. The artery was injured during closure of the aortotomy, as determined at autopsy. Acute right ventricular failure was obvious at the time of weaning from bypass, and right ventricular function did not improve with intraaortic balloon pumping and inotropic support. In our opinion, the cause of right ventricular failure after aortic valvular operations is usually due to mechanical damage to the RCA, although other causes such as air embolism and inadequate myocardial protection should be considered. Anatomic variations of the RCA may contribute to damage to that artery during aortic operations. In any situation in which acute right ventricular failure occurs during an aortic valvular operation and does not improve with reperfusion, we continue to recommend that the RCA be bypassed.

This article has been cited by other articles:

				A. Aris, M. L. Camara, J. Montiel, L. J. Delgado, J. Galan, and H. Litvan Ministernotomy versus median sternotomy for aortic valve replacement: a prospective, randomized study Ann. Thorac. Surg., June 1, 1999; 67(6): 1583 - 1587. [Abstract] [Full Text] [PDF]

				M. Gaudino, F. Glieca, P. Bruno, F. L. Piancone, F. Alessandrini, and G. Possati Unusual Right Coronary Artery Anomaly With Major Implication During Cardiac Operations Ann. Thorac. Surg., September 1, 1997; 64(3): 838 - 839. [Abstract] [Full Text]

This Article Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hiraaki Goto Tomas A. Salerno Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Utoh, J. Articles by Bergsland, J. Search for Related Content PubMed PubMed Citation Articles by Utoh, J. Articles by Bergsland, J.