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

Abstract

An anomalous origin of the left circumflex coronary artery that arises as a side branch of the right coronary artery and encircles the aortic annulus is usually an incidental finding. However, in patients undergoing aortic valve/root procedures, its existence can significantly complicate the surgical treatment. We report our operative strategy with three different prostheses without valve downsizing.

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

“…No intervention had been made in four of these deaths despite the diagnosis of LCx compression [4,15,38]. On the contrary, some kind of intervention was offered to all the survivors after LCx compression diagnosis [1][2][3]7,8,16,17,26,28,29,36,37]. Therefore, mortality was 80% when no intervention was made, whereas mortality was zero when intervention was intraoperatively offered.…”

“…If the onset of myocardial ischemia in cases of AVR or multivalvular replacement on the ground of LCx of anomalous origin is postoperative, PCI can be reasonably employed to relieve myocardial ischemia [1,16,28] (Fig. 3).…”

“…According to Dr Angelini's thorough research on coronary anomalies, the overall incidence of coronary anomalies in a continuous series of 1950 patients was 5.64%, whereas the incidence of AOCA was 1.07% [21]. Most of the times, AOCA concerns an incidental finding during cardiac catheterization [16] (Fig. 2a and 2c).…”

“…The distal portion of LCx normally lies within the atrioventricular groove but an abnormal retro-aortic course is followed between that point and its anomalous origin from the right aortic sinus [2]. The anomalous vessel travels between the aortic root and the left atrial wall, nearly at the level of the mitral annulus [15,16], thus potentially leading to major complications during aortic valve surgery [8,17,18]. Conditions are even worse when both the aortic and mitral valves are replaced.…”

“…Moreover, bicuspid aortic valves are more often related to coronary anomalies [17]. Although appropriate angiographic imaging can provide with critical details regarding the anatomic relations between the anomalous coronary vessel and aortic valve and root structures, coronary angiography is not typically recommended in young patients when risk factors for coronary artery disease are absent [16]. Therefore, given the aforementioned data, it would be justified to perform coronary angiography or at least a computed tomography coronary angiogram on all AVR candidates regardless of age in case a coronary anomaly is detected [3].…”