Aortic Valve Replacement in Patients with an Anomalous Left Circumflex Artery: Technical Considerations

Anomalous circumflex artery: a benign variant generating a malignant potential after valve surgery

Coronary artery anomalies are a diverse group of congenital disorders presenting with highly variable clinical manifestations. The anomalous origin of left circumflex artery from the right coronary sinus following a retro-aortic trajectory is a well-recognized anatomic variation. Despite its benign course, it can prove lethal in association with valvular surgery. When single aortic valve replacement or combined with mitral valve replacement is performed, the aberrant coronary vessel may be compressed by or between the prosthetic rings triggering postoperative lateral myocardial ischemia. If left untreated, the patient is at risk of sudden death or myocardial infarction with its detrimental complications. Skeletonization and mobilization of the aberrant coronary artery is the most widely accepted intervention, but valve downsizing or concomitant surgical or transcatheter revascularization have also been described. However, large series are lacking from the literature. Therefore, no guidelines exist. This study is a thorough review of the literature concerning the aforementioned anomaly in association with valvular surgery.

Aortic valve replacement of a quadricuspid aortic valve with right coronary artery ostium adjacent to one of the commissures

BACKGROUND

Quadricuspid aortic valve is a rare congenital heart disease that may be associated with a different anatomical relationship between the coronary artery ostium and the commissure.

CASE PRESENTATION

Herein, we report a case of a 59-year-old woman who underwent aortic valve replacement for a quadricuspid aortic valve with severe aortic regurgitation. Intraoperatively, the aortic valve had four cusps of almost equal size and the right coronary artery arose adjacent to the commissure between the right coronary cusp and one of the two non-coronary cusps. The annular stitches were placed in a non-everting mattress fashion with pledgets on the ventricular side, and stitches near the right coronary ostium were transitioned to the subannular ventricular myocardium to maintain the distance from the ostium. A one-step smaller-sized prosthesis was selected to avoid an oversized prosthetic valve potentially compressing the right coronary ostium.

CONCLUSIONS

When performing aortic valve replacement for a quadricuspid aortic valve, careful observation of the coronary location and means to avoid coronary ostium obstruction are essential.

Surgical aortic valve replacement in the setting of anomalous circumflex coronary artery

BACKGROUND

The anomalous circumflex coronary artery (ACCA) from the right coronary artery or sinus of Valsalva lies in proximity to the aortic valve annulus. We sought to determine the prevalence of injury to the ACCA during surgical aortic valve replacement (SAVR).

METHODS

We queried the Cardiac Surgery and Cardiology databases for all patients who received SAVR in the setting of an ACCA. We identified 31 patients operated from September 2002 through December 2018. The endpoint was myocardial ischemia in the distribution of the ACCA.

RESULTS

The patient mean age was 69 ± 11 years, sex was female in 8 patients (26%), and ejection fraction was 62% (interquartile range 59-68). No patient received exploration of the ACCA, but 6 (19%) received a coronary artery bypass graft (CABG) to the ACCA. No patient demonstrated myocardial infarction or received perioperative intervention on the ACCA; however, discharge echocardiography demonstrated new lateral wall motion abnormality in 5 (16%) patients which was associated with a reduction in ejection fraction of -11% from baseline (P=0.007). CABG to the ACCA was not protective of new lateral wall motion abnormality (P=0.968). Mortality was 34 ± 10% at 10 years and was not associated with new lateral wall motion abnormality (Log rank test P=0.183).

CONCLUSIONS

Clinically apparent myocardial infarction was not identified following SAVR, but echocardiography evidence of myocardial ischemia in the distribution of the ACCA was identified in 16% of patients. Protective adjuvant intervention on the ACCA may be indicated. Further study is warranted.

Surgical repair of anomalous aortic origin of coronary artery in adults

Anomalous aortic origin of a coronary artery is a congenital abnormality of the origin or course of a coronary artery that arises from the aorta. The surgical treatment of this anomaly is highly variable and controversial and is achieved by implementing elaborate techniques of anatomic repair or by simple coronary artery bypass grafting. This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two independent reviewers determined whether studies met the inclusion criteria. Eligible papers were published in English, clinical studies describing surgical repair of anomalous aortic origin of a coronary artery including coronary artery bypass in adults, and enrolled >5 patients. In the absence of multicentre trials, 7 single-center retrospective series were included, which demonstrated comparable short- and midterm outcomes of anatomic repair and coronary artery bypass in adults with anomalous aortic origin of a coronary artery. Coronary unroofing was the preferred technique when the anomalous artery has an intramural component, but there is a risk of aortic insufficiency. Anatomic repair is technically demanding and should be carried out in experienced centers. Coronary artery bypass with internal thoracic artery or vein grafts is technically straightforward with low operative risk and comparable midterm outcomes, however, long-term outcomes are unknown. Coronary artery bypass grafting is the technique of choice for older patients, in those with concomitant coronary artery disease, as a bailout procedure for failed anatomic repair, or in centers without experience in anatomic repair for anomalous aortic origin of a coronary artery.

Aortic Valve Replacement in 8 Adults with Anomalous Aortic Origin of Coronary Artery

Patients with anomalous origin of a coronary artery during aortic valve replacement (AVR) are at risk of coronary compromise. Large case series are lacking. In this retrospective study, we review our experience with this condition. From August 2014 through June 2016, 8 adult patients (mean age, 74 ± 17.5 yr; age range, 33-86 yr; 5 men) with anomalous aortic origin of a coronary artery underwent surgical or transcatheter AVR at our institution. Six patients had aortic stenosis; 2 had aortic insufficiency, one of whom had an associated aortic root aneurysm. In 7 patients, the left anomalous coronary artery originated from the right aortic sinus, and in one, the right coronary artery arose from the left cusp. The anatomic course was revealed by means of 3-dimensional computed tomographic angiography. No patient underwent primary aortic reimplantation of the anomalous artery. Two had the artery mobilized from encircling the annulus too closely and then underwent coronary artery bypass grafting. Two high-risk patients underwent transcatheter AVR. After surgical AVR, 2 patients had perioperative myocardial infarction caused by coronary compression, so percutaneous coronary intervention was performed. One patient died of sepsis 3 months after discharge from the hospital. In our patients, AVR sometimes led to severe perioperative complications. Successful AVR depended on 3-dimensional computed tomographic angiographic findings, individual anatomic variations, and appropriate treatment choices.

Unrecognized anomalous left circumflex coronary artery arising from right sinus of Valsalva: a source of perioperative complication

: In this article we provide a very interesting and challenging PCI of unrecognized anomalous left circumflex coronary artery (LCx) arising from right sinus of Valsalva (RSV) after aortic valve replacement (AVR).This case presentation focuses the attention on important criteria for recognition of abnormal LCx coronary artery, that is the most frequent congenital coronary variant. Failure to demonstrate the anomaly can lead to erroneous interpretation of coronary anatomy with fatal complication in case of aortic valve replacement, as a consequence of accidental ligation or compression of the anomalous vessel. This procedure, especially in the presence of a bioprosthesis aortic valve just implanted, constitutes a challenge for the interventional cardiologist and at the same time a question mark regarding the strategy, choice of guiding catheter, guide wire, and type of stent to use.