Ann Thorac Surg 2002;73:647-649
© 2002 The Society of Thoracic Surgeons
Case report
Aortic root replacement with anomalous origin of the coronary arteries
Stacy B. O’Blenes, MD, MSa,
Christopher M. Feindel, MD*a
a Division of Cardiovascular Surgery, The Toronto Hospital, University of Toronto, Toronto, Ontario, Canada
Accepted for publication June 22, 2001.
* Address reprint requests to Dr Feindel, The Toronto Hospital, E 14-222, 200 Elizabeth St, Toronto, Ontario, Canada M5G 2C4
e-mail: chris.feindel{at}uhn.on.ca
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Abstract
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Coronary arteries with anomalous origin from the aorta can be at risk during aortic valve procedures. We report a case of origin of the circumflex and left coronary artery from the proximal right coronary artery in a patient with a bicuspid aortic valve and aortic root aneurysm. Attention to the anatomic relationship of the anomalous arteries to the aorta allowed safe aortic root replacement.
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Introduction
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Anomalous origin of a coronary artery from the aorta is usually an incidental finding; however, if not recognized, it can lead to serious complications during cardiac operations. Specifically, an anomalous coronary artery may be at risk of injury during aortic or mitral valve operations [1, 2]. We report the treatment of a patient with a single coronary trunk arising from the right coronary sinus associated with an insufficient bicuspid aortic valve and aortic root aneurysm. The significance of coronary artery anomalies during aortic root operation is discussed.
The patient, 68-year-old male, had been followed for 15 years with moderate aortic insufficiency secondary to a prolapsing bicuspid aortic valve. Serial echocardiography revealed increasing left ventricular dimensions and reduced ventricular function with an ejection fraction of 36% confirmed by radionuclide angiography. The aorta was dilated measuring 39 mm at the annulus, 52 mm at the sinuses, and 43 mm at the ascending aorta, tapering to 32 mm at the arch. Coronary angiography revealed a dominant right coronary artery (RCA) with anomalous circumflex and left anterior descending (LAD) coronary arteries, both arising from the proximal RCA (Fig 1A).
The anomalous circumflex artery coursed lateral then posterior to the aorta to enter the atrioventricular groove and supply the lateral wall. The LAD appeared to travel in the basal septum to reach the anterior wall, where it had a relatively small distribution.
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Fig 1. (A) Angiogram demonstrating origin of circumflex (CIRC) and left anterior descending (LAD) from the proximal right coronary artery (RCA). (B) Intraoperative photograph of the aortic root demonstrating origin of left anterior descending and right coronary artery (RCA) from a common anterior coronary trunk. (C) Intraoperative photograph demonstrating course of the anomalous circumflex (arrows) in relation to the aortic annulus. (D) Intraoperative photograph demonstrating the relationship of the anomalous circumflex (arrows) to the anastamosis of the bioprosthesis and the aortic annulus. Cannulation of the left anterior descending and proximal right coronary artery through the single coronary ostium for delivery of cardioplegia is also shown (arrowheads).
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Aortic root replacement was performed with the aid of cardiopulmonary bypass and passive hypothermia to 34°C. Aortotomy revealed a single anterior located coronary ostium. The origin of the LAD was visible approximately 3 mm beyond the ostium of the common trunk (Fig 1B). The heart was arrested with continual antegrade cold blood cardioplegia delivered by direct cannulation of the LAD. A second cannula was placed in the proximal RCA to supply the RCA and circumflex territories (Fig 1D).
The anomalous circumflex artery was identified immediately adjacent to the aorta under the visceral pericardium. It was dissected from the aortic wall along its entire course lateral and then posterior to the aorta at the level of the annulus (Fig 1C). Once the coronary button was mobilized, the LAD was identified as it entered the interventricular septum immediately after its origin from the common coronary trunk.
A size 29 Medtronic Freestyle bioprosthesis (Medtronic, Minneapolis, MN) was sutured to the debrided aortic annulus while paying particular attention to the circumflex and LAD (Fig 1D). A single opening was made in the anterior sinus to which the single coronary button was anastomosed. The distal anastomosis of the bioprosthesis to the aorta was completed and the heart was carefully de-aired. The patient was weaned from cardiopulmonary bypass in sinus rhythm. Intraoperative transesophageal echocardiography revealed a segmental wall motion abnormality in the LAD territory that resolved spontaneously over a few minutes and was believed to represent air embolism down the anterior located LAD. The postoperative electrocardiogram was unchanged from before operation and echocardiography performed before discharge home revealed a normally functioning bioprosthesis and no segmental wall motion abnormalities.
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Comment
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The incidence of anomalous origin of a coronary artery from the aorta is approximately 0.5% to 1% [3, 4]. The most common anomaly is origin of the circumflex from the RCA or the right sinus of Valsalva with a course lateral then posterior to the aortic root. Origin of all three coronary arteries from a single anterior trunk is exceedingly rare. An anomalous circumflex encircling the aortic root can be injured by deeply placed sutures or compressed by a prosthetic ring during aortic or mitral valve procedures [1, 2]. As illustrated by this patient, the anomalous circumflex is at particular risk during aortic root operation because of its anatomic location immediately adjacent to the aortic wall at the level of the annulus. If not recognized, the anomalous circumflex can be injured during resection of the noncoronary and left coronary sinus of Valsalva or during an annular enlargement incision. To prevent injury, the anomalous artery should be carefully dissected away from the aortic wall as we have demonstrated (Fig 1C).
Cardioplegia can be effectively delivered by direct cannulation of the coronary ostia providing the cannulas do not obstruct the early takeoff of an anomalous artery from the RCA. Retrograde cardioplegia delivered through the coronary sinus is an alternative strategy.
Origin of all three coronary arteries from a single trunk allows reimplantation as a single anterior button. However, the anomalous LAD enters the ventricular septum immediately after its origin from the RCA and restricts mobility of the coronary button. Careful planning is required for successful reimplantation and thorough de-airing is necessary to avoid the possibility of air embolism into the single anterior coronary trunk.
Coronary artery anomalies and bicuspid aortic valve have been described as risk factors for coronary complications after aortic root replacement [5]. We believe that aortic root operation in patients with anomalous coronary arteries can be performed safely if the anatomy is clearly understood in advance. Coronary artery anomalies appear to be more common in patients with aortic valve pathology, therefore liberal criteria for preoperative angiography may be justified [3, 4]. Cardiac magnetic resonance imaging may be helpful to demonstrate the spatial relationship of the anomalous arteries to the aortic root if the angiographic anatomy is unclear [6].
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References
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Abstract
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