Intraoperative myocardial ischemia during renal transplantation caused by anomalous origin of the right coronary artery

Abstract

Anomalous origin of the right coronary artery (AORCA) is a rare congenital anomaly with an incidence of 0.92% during routine cardiac catheterization. Its presence raises an important concern to the anaesthesiologist because it can lead on to myocardial ischaemia manifesting as either angina pectoris or myocardial infarction, or sudden death in young patients with minimal exertion, even in the absence of atherosclerosis. Patients with AORCA may be intolerant to stress and the high cardiac output condition owing to volume loading. Such a therapeutic manoeuvre may be desirable during renal transplantation to enable better perfusion of the renal graft immediately after grafting the kidney, in order to improve its function. Hence, haemodynamic goals in renal transplant recipient with AORCA can be contradictory during surgery, thereby rendering anaesthetic management challenging. We report a case of acute myocardial ischemia precipitated by fluid loading conditions in a patient with AORCA during renal transplant that was successfully treated with emergent intra-aortic balloon pump therapy intraoperatively. Judicious intraoperative fluid replacement is recommended, and volume overload must be avoided in AORCA patients undergoing surgery.

Potential for Using 3D Technology to Image the Origins of the Coronary Arteries

“…These include interarterial, retro-aortic, and anterior to the pulmonary trunk. 21 The interarterial type ( Figure 5) is most worrisome because the proximal portion of the coronary artery courses between the aorta and the main pulmonary artery from the contralateral coronary sinus, crossing to the appropriate side of the heart. Myocardial ischemia can occur, inducing angina, myocardial infarction, life-threatening arrhythmias, syncope, and sudden death.…”