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Ann Thorac Surg 1997;64:838-839
© 1997 The Society of Thoracic Surgeons

Case Report

Unusual Right Coronary Artery Anomaly With Major Implication During Cardiac Operations

Mario Gaudino, MD, Franco Glieca, MD, Piergiorgio Bruno, MD, Felice Luca Piancone, MD, Francesco Alessandrini, MD, Gianfederico Possati, MD

Department of Cardiac Surgery, Catholic University, Rome, Italy

Accepted for publication April 8, 1997.


   Abstract
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We report a case in which an unrevealed high origin of the right coronary artery (almost 4 cm above the left coronary sinus) led to major complications during a routine atrial septal defect closure. We stress that, in absence of preoperative coronary angiography, coronary artery anomalies should always be considered and minimal ascending aorta manipulation and antegrade/retrograde myocardial protection should be recommended.


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Aberrant aortic origin of the right coronary artery (RCA) is a rare congenital anomaly occurring in less than 0.1% of the patients who undergo coronary angiography. In the majority of cases this type of anomaly is asymptomatic and constitutes an accidental angiographic finding [1]. We herein report a case in which an unnoticed aberrant aortic origin of the RCA led to major complications during a routine cardiac operation.

A 17-year-old boy was admitted to our institution due to palpitations and dyspnea on moderate effort. Preoperative transthoracic echocardiography demonstrated an isolated type II atrial septal defect with significant left-to-right shunt. Cardiac catheterization was not considered necessary and the patient was scheduled for operation a few days after admission.

At operation the ascending aorta and the two venae cavae were cannulated as usual, cardiopulmonary bypass was started, and antegrade/retrograde warm blood cardioplegia was infused. The atrial septal defect was closed by simple suture.

Immediately after removal of the aortic clamp, important bleeding from the ascending aorta was noted. Despite the application of hemostatic stitches, the bleeding was extremely difficult to control and soon became associated with ischemic electrocardiographic changes in the inferior leads and hemodynamic deterioration. Emergency cardiopulmonary bypass was started and antegrade/retrograde cardioplegia was infused again.

After dissection of the ascending aorta an aberrant coronary artery, arising from the left anterior aspect of the ascending aorta (just opposite to the origin of the brachiocephalic trunk), was identified. This coronary artery coursed on the left anterior aspect of the ascending aorta, between the aorta and the pulmonary trunk, before entering the atrioventricular groove (Fig 1Go). The distal distribution was that of a normal RCA.



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  		Fig 1. . Schematic representation of the origin of the coronary arteries in our patient. (LMCA = left main coronary artery; RCA = right coronary artery.)

 
In the absence of any preoperative data about the coronary artery anatomy and to identify the origin of the left main trunk (thus excluding the possibility of a lesion of the left coronary artery) we opened the ascending aorta. The origin of the left coronary artery was found in its normal position and no right coronary ostium was seen in correspondence with the sinuses of Valsalva. The right coronary ostium was located on the left anterior aspect of the ascending aorta, just in front of the brachiocephalic trunk. The aberrant RCA had been damaged near its origin during the application of the aortic clamp. The artery had then been occluded by the clamp itself, so that the damage became apparent only after clamp removal.

The right internal mammary artery was then harvested and anastomosed to the mid-tract of the RCA. The patient was successfully weaned from cardiopulmonary bypass without any ischemic electrocardiographic or echocardiographic modification. The postoperative course was uneventful, and the patient was discharged on the 7th postoperative day.


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The incidence of anomalous aortic origin of the RCA in the general population is unknown [1]; however, this type of malformation is reported in 0.07% to 0.1% of the patients referred for coronary angiography [2]. This type of anomaly is usually considered of little clinical significance and is not treated in absence of specific clinical symptoms [3]. The most common variation is an RCA originating from the left sinus of Valsalva, anterior to the left coronary ostium [4].

Coronary arteries originating above the sinuses of Valsalva are thought to be quite common in the overall population [5]; however, the vertical displacement is usually limited to few millimeters [5, 6]. In our case, the RCA originated in an unusually high position (almost 4 cm above the aortic valve) in correspondence with the left coronary sinus.

Due to its course along the ascending aorta this type of anomalous RCA is particularly prone to injury during aortic manipulation (as in our case). Moreover, this type of RCA crosses the area where the aortic clamp is usually positioned and, if undetected, is inevitably occluded during aortic cross-clamping, leading to inadequate protection of the right ventricle when antegrade cardioplegia is used.

In this cost-containing era, preoperative cardiac catheterization is usually reserved for patients older than 35 or 40 years [7], and almost all young patients undergo routine valvular or congenital cardiac operations without preoperative coronary angiography. In this setting, coronary artery anomalies can easily remain unrevealed. Recently, Utoh and Goto [8] described a case in which an unnoticed anomalous aortic origin of the RCA led to catastrophic complications during routine aortic valve replacement.

In conclusion, this particular aortic origin of the RCA is a congenital anomaly with major potential implications during cardiac operations. In general, coronary artery anomalies should always be considered during cardiac operations in the absence of preoperative coronary angiography. Minimal ascending aorta dissection and manipulation and antegrade/retrograde myocardial protection are recommended in these cases.


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Address reprint requests to Dr Gaudino, Divisione di Cardiochirurgia, Policlinico A. Gemelli, Largo A. Gemelli 8, 00168 Rome, Italy.


   References
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 References
 

  1. Kimbiris D, Iskandrian AS, Segal BL, Bemis CE. Anomalous aortic origin of coronary arteries. Circulation 1978;58:606–15.[Free Full Text]
  2. 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]
  3. Liberthson RR, Dinsmore RE, Fallon JT. Aberrant coronary artery origin from the aorta. Circulation 1979;59:748–54.[Abstract/Free Full Text]
  4. Roberts WC. Major anomalies of coronary arterial origin seen in adulthood. Am Heart J 1986;111:941–63.[Medline]
  5. Baim DS, Harrison DC. Non atherosclerotic coronary artery disease. In: Hurst JW. The heart, 6th ed. New York: McGraw-Hill, 1986:1016–25.
  6. Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary angiography. Cathet Cardiovasc Diagn 1990;21:28–40.[Medline]
  7. Kirklin JW, Barratt-Boyes BG, eds. Cardiac surgery, 2nd ed. New York: Churchill Livingstone, 1993:609–43.
  8. Utoh J, Goto H. Anomalous origin of the right coronary artery as a risk factor in aortic valve surgery. Ann Thorac Surg 1996;62:1886.[Free Full Text]



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