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

Abstract

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.

Mobilization of an anomalous retro aortic coronary artery to prevent myocardial ischemia after aortic valve replacement

“…[3] Although only a few reports addressed this issue to date, best outcomes are described when mobilization of the anomalous retro aortic coronary artery is performed. [4] Bypass grafting of the left circumflex has been used [5] , but initial competitive flow from the patent native vessel may render it useless. Implantation of undersized prosthesis, with sutures low below the aortic annulus, did not avoid coronary compression and the need for urgent percutaneous intervention after surgery [5] .…”

Mobilization of an anomalous retroaortic coronary artery to prevent myocardial ischemia after aortic valve replacement

“…Implantation of an undersized prosthesis with sutures placed low below the aortic annulus did not prevent coronary compression or the requirement for urgent percutaneous intervention after surgery. 5 Implantation of a stentless bioprosthesis may prevent the compressive effect of the rigid ring of the stented valves on the anomalous coronary artery. 2 However, the risk of coronary damage, distortion, or ligation still exists during valve implantation.…”

“…Bypass grafting of the left circumflex has been used, 5 but the initial competitive flow from the patent native vessel may render it useless. Implantation of an undersized prosthesis with sutures placed low below the aortic annulus did not prevent coronary compression or the requirement for urgent percutaneous intervention after surgery 5 …”

Should we ignore asymptomatic anomalous coronary arteries in patients presenting for aortic valve replacement?

“…An essential tool for proper assessment and planning is a three-dimensional computed tomographic reconstruction angiography. 5,8 In the context of aortic valve surgery, it is of interest to note that the incidence of anomalous coronary arteries is significantly higher among patients with bicuspid aortic valves (BAV), further the incidence of postoperative ischemic complications and the need for subsequent coronary interventions is significantly higher among patients with concomitant coronary abnormalities. 9,10 Alameddine et al 8 described their experience with eight patients with an anomalous aortic origin of a coronary artery who underwent aortic valve replacement.…”

“…5,8 In the context of aortic valve surgery, it is of interest to note that the incidence of anomalous coronary arteries is significantly higher among patients with bicuspid aortic valves (BAV), further the incidence of postoperative ischemic complications and the need for subsequent coronary interventions is significantly higher among patients with concomitant coronary abnormalities. 9,10 Alameddine et al 8 described their experience with eight patients with an anomalous aortic origin of a coronary artery who underwent aortic valve replacement. Two of these patients had a postoperative myocardial infarction caused by compression of the anomalous vessel, interestingly both had a BAV and in both the valve was undersized.…”