Incidental finding of anomalous circumflex coronary artery from right coronary sinus prior to aortic valve surgery

Abstract

Anomalous origin of the left circumflex (Cx) artery is a common and mostly benign coronary artery anomaly. We report the case of a man aged 52 years who presented to his local hospital with progressive breathlessness on exertion and syncopal episodes. His admission transthoracic echocardiography (TTE) showed bicuspid aortic valve, severe aortic stenosis with a valve area of 0.5 cm and his left ventricular ejection fraction (LVEF) was 27%. His coronary angiogram showed normal coronary arteries but anomalous origin of the Cx artery from the right coronary. He underwent elective bioprosthetic aortic valve replacement. His postoperative recovery was uneventful and he was discharged on day 5 postoperatively. His TTE postoperatively showed well-seated aortic valve, improved LVEF to 51%. We here report a case of incidental finding of anomalous Cx artery arising from the right coronary while the patient is being worked up for aortic valve replacement for congenital bicuspid aortic valve.

AVR in patients with anomalous course of the circumflex artery without prosthetic downsizing

“…Coronary anomalies such as anomalous left circumflex coronary artery (LCA) arising from the right sinus of Valsalva, strictly leaning on the aortic annulus, can have serious consequences in AV/ root surgery, particularly if unrecognized or underestimated. 3,4 In this paper, we present three patients with an anomalous course of the LCA undergoing AV replacement (AVR) with three different prostheses, without prosthetic downsizing. If open surgery is not indicated or alternative technique are not available, transcatheter AV implantation has been described with success, using when necessary, a coronary guidewire before deploying transcatheter aortic valve implantation to prevent coronary occlusion/stenosis.…”

“…In addition, the low incidence of this anomaly in clinical practice could reduce the proper attention of surgeons, particularly when critical stenoses are notreported. Anomalous LCA with a retro-aortic trajectory has major implications during AV surgery, particularly when unrecognized or underestimated [3][4][5]. Injury to the LCA may occur in isolated AVR by compression from the prosthesis (sewing ring) or ligation by annular sutures while resection of the noncoronary sinus or suturing could complicate aortic root/sinus repair.…”

Bicuspid aortic valve and sports: From the echocardiographic evaluation to the eligibility for sports competition

“…A comprehensive echocardiographic evaluation of athletes with BAV is crucial for their management and should identify the type of BAV and should include the assessment of aortic valve function, left ventricular size and function, and aortic size, from aortic root to aortic arch. In rare cases, BAV is associated with an anomalous origin of coronary arteries 33,34 . Therefore, in athletes with BAV, as well as for the entire athletic population, a careful echocardiographic examination must also include the identification of coronary ostia.…”

AVR in patients with anomalous course of the circumflex artery without prosthetic downsizing

“…Nevertheless, coronary angiography and/or CT-scan are not always performed before aortic valve (AV) surgery (young patients without risk factors or urgent cases like endocarditis) or can be undervalued when stenotic lesions are excluded. Coronary anomalies such as anomalous left circumflex coronary artery (LCA) arising from the right sinus of Valsalva, strictly leaning on the aortic annulus, can have serious consequences in aortic valve/root surgery, particularly if unrecognized or underestimated [3,4]. In this paper, we present three patients with an anomalous course of the LCA undergoing AV replacement (AVR) with three different prostheses, without prosthetic downsizing.…”

“…In addition, the low incidence of this anomaly in clinical practice could reduce the proper attention of surgeons, particularly when critical stenoses are not reported. Anomalous LCA with a retro-aortic trajectory has major implications during AV surgery, particularly when unrecognized or underestimated [3][4][5]. Injury to the LCA may occur in isolated AVR by compression from the prosthesis (sewing ring) or ligation by annular sutures while resection of the non-coronary sinus or suturing could complicate aortic root/sinus repair.…”