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Ann Thorac Surg 1998;66:2093-2094
© 1998 The Society of Thoracic Surgeons

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Case Reports

Compression of anomalous circumflex coronary artery by a prosthetic valve ring

^a Ottawa CivicUniversity of Ottawa Heart Institute, and Departments of Pathology, Laboratory Medicine, and Surgery, University of Ottawa, Ottawa, Ontario, Canada
^b Ottawa General HospitalsUniversity of Ottawa Heart Institute, and Departments of Pathology, Laboratory Medicine, and Surgery, University of Ottawa, Ottawa, Ontario, Canada
^c Division of Cardiovascular Surgery, Heart Institute, University of Ottawa, Ottawa, Ontario, Canada

Accepted for publication July 20, 1998.

Address reprint requests to Dr Veinot, Department of Laboratory Medicine, Ottawa Civic Hospital, 1053 Carling Ave, Ottawa, Ontario, Canada

	Abstract

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Anomalous origin of the circumflex coronary artery from the right aortic sinus, with a retroaortic course, is usually without consequence. We report a patient who underwent aortic valve replacement for bicuspid aortic valve. The prosthesis sewing ring distorted the circumflex, producing myocardial infarcts and sudden death during exercise.

	Introduction

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Anomalous origin of the coronary arteries may be associated with sudden death or may be an incidental finding. Anomalous origin of the circumflex artery from the proximal right coronary artery or from the right aortic sinus usually has a benign clinical course. We report a man who underwent aortic valve replacement for a regurgitant congenitally bicuspid valve with aortoannular ectasia. Five years postoperatively he died suddenly during exercise. Autopsy found anomalous origin of the circumflex artery from the right aortic sinus and recent and old lateral left ventricular infarcts. Although this abnormality had been recognized, the valve prosthetic ring had distorted the artery leading to infarction.

	Case report

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This 29-year-old male aerobics instructor had severe aortic regurgitation with fatigue and dyspnea. Echocardiography revealed a bicuspid aortic valve with severe regurgitation, a left ventricular end-diastolic diameter of 8.1 cm and a left ventricular end-systolic diameter of 4.6 cm. Cardiac catheterization confirmed severe aortic regurgitation and anomalous circumflex origin from the right sinus of Valsalva, with retroaortic course.

The patient underwent aortic valve replacement with a No. 29 Medtronic Hall prosthesis (Medtronic, Minneapolis, MN) using interrupted pledgeted sutures inserted from the aortic side. The heart was protected with intermittent doses of crystalloid cardioplegia administered directly in the coronary ostia. The postoperative course was uneventful.

In the weeks after the operation the patient complained of palpitations. Because of T-wave abnormalities, inferior wall ischemia was entertained. The patient did well and the T-wave abnormalities became more normal. At no time did the patient complain of any chest pain. Five years postoperatively the patient died suddenly while jogging.

Autopsy findings
Findings were limited to the 525-g heart, which had severe fibrous pericardial adhesions. The No. 29 Medtronic Hall mechanical aortic prosthesis was well seated and without thrombus.

There was anomalous origin of the circumflex coronary artery with separate origin from the right aortic sinus (Fig 1). The vessel had a retroaortic course below the prosthetic ring (Fig 1 and 2A) supplying branches to the posterolateral left ventricle and terminating in the usual manner. No ostial ridges were seen. The left anterior descending and right coronary arteries were unremarkable.

View larger version (17K): [in this window] [in a new window]   Fig 1. Diagram showing nomalous origin of the circumflex (Circ), with retroaortic course and compression by the prosthesis valve ring. (LAD = left anterior descending coronary artery; RCA = right coronary artery.)

View larger version (113K): [in this window] [in a new window]   Fig 2. (A) Right lateral aorta view showing right coronary artery (large arrow) and circumflex artery (small curved arrow) with acute angle of takeoff and retroaortic course; (B) Posterior aorta view showing fibrous shelf secondary to the prosthesis ring. The shelf compromises the circumflex artery (open arrow).

The lateral left ventricle had a large previous transmural infarct and a recent infarct.

	Comment

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Coronary artery anomalies occur in approximately 1% to 2% of patients [1,2] and include (1) anomalous origin, (2) anomalous distribution, (3) abnormal connection between a coronary artery and another blood vessel or cardiac chamber, and (4) an abnormality as part of a complex congenital abnormality.

Origin of the circumflex coronary artery from the right aortic sinus is the most common anomaly encountered [1–3]. The artery may have a separate ostium in the sinus, share an ostium with the right coronary artery, or take origin from the proximal right coronary artery. Angiographic misinterpretation as an occluded circumflex is possible, and the anomaly may be missed if the angiogram catheter is inserted past the origin of the anomalous vessel.

Anomalous origin of a coronary artery from the opposite aortic sinus, with course between the great arteries, has been associated with sudden death. The artery is thought to compress because of the acute angle of vessel takeoff, obstructive ostial valvelike ridges, and arterial compression during exercise from aortic root expansion [4]. Study of patients with these abnormalities found no specific pathologic feature predictive of sudden death [5]. Retroaortic course of the circumflex coronary artery is usually a benign or incidental finding without consequence [3].

Coronary artery injury during valvular operation may occur by occlusion of the ostium by the prosthetic ring or by dissection, laceration, or suture of the artery [6].

Injury of a retroaortic circumflex artery that arose from the right coronary artery has been reported in 2 patients. One patient had aortic and mitral valve replacement with Starr-Edwards prostheses, with circumflex compression between the rings. The second patient had a mitral valve replacement with a Starr-Edwards prosthesis, with circumflex compression by the ring [6]. If not recognized preoperatively, the artery may not be perfused during operation.

In the current patient, the prosthetic valve ring distorted the circumflex producing severe intimal damage proximally and thrombotic occlusion in the mid-vessel. The previous and recent infarcts are attributable to the resultant poor perfusion of the lateral myocardium. This area would be at risk for poor perfusion, and with exercise, the area became ischemic. Death almost certainly occurred as a result of an arrhythmia from the combination of a recent and a previous infarct.

In a similar situation one should consider a smaller-sized prosthesis with an aortoplasty, a homograft, or a stentless prosthesis. Depending on the age of the patient, and hopefully the diagnosis being established preoperatively, a decision regarding the technique to be used would have been discussed with the patient.

	References

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1. Hobbs R.E., Millit H.D., Raghavan P.V., Moodie D.S., Sheldon W.C. Congenital coronary artery anomalies: clinical and therapeutic implications. Cardiovasc Clin 1981;12:43-58.[Medline]
2. Roberts W.C. Major anomalies of coronary arterial origin seen in adulthood. Am Heart J 1986;111:941-963.[Medline]
3. Page H.L.J., Engel H.J., Campbell W.B., Thomas C.S.J. Anomalous origin of the left circumflex coronary artery: recognition, angiographic demonstration and clinical significance. Circulation 1974;50:768-773.[Abstract/Free Full Text]
4. Virmani R., Chun P.K.C., Goldstein R.E., Robinowitz M., McAllister H.A. Acute takeoffs of the coronary arteries along the aortic wall and congenital ostial valve-like ridges: association with sudden death. JACC 1984;3:766-771.[Abstract]
5. Taylor A.J., Byers J.P., Cheitlin M.D., Virmani R. Anomalous right or left coronary artery from the contralateral coronary sinus: "high-risk" abnormalities in the initial coronary artery course and heterogeneous clinical outcomes. Am Heart J 1997;133:428-435.[Medline]
6. Roberts W.C., Morrow A.G. Compression of anomalous left circumflex coronary arteries by prosthetic valve fixation rings. J Thorac Cardiovasc Surg 1969;57:834-838.[Medline]

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				R. M. Flores and J. G. Byrne Aortic valve replacement with an anomalous left circumflex coronary artery encircling the aortic anulus J. Thorac. Cardiovasc. Surg., February 1, 2001; 121(2): 0396 - 397. [Full Text] [PDF]

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