Asian Cardiovasc Thorac Ann 2003;11:169-170
© 2003 Asia Publishing EXchange Ltd
Aortic Valve Replacement in a Patient With an Aberrant Left Coronary Artery
Ahmed A. Alsaddique, MD,
Mohammed M. Elsaegh, MD,
Mohammed A. Fouda, FRCS
Division of Cardiac Surgery, College of Medicine and King Khalid University Hospital, Riyadh, Saudi Arabia
For reprint information contact: Ahmed A. Alsaddique, MD Tel: 966 1 467 1575 Fax: 966 1 467 9493 email: alsadd{at}ksu.edu.sa College of Medicine and King Khalid University Hospital, P.O. Box 7805, Riyadh 11472, Saudi Arabia.
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ABSTRACT
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A 22-year-old male undergoing aortic valve replacement was found to have the left coronary ostium arising from the noncoronary cusp area in close proximity to the annulus. He could not be weaned off cardiopulmonary bypass after the operation, even after removal of a Teflon pledget thought to obstruct the left coronary ostium. He underwent bypass grafting to the left coronary system and was then easily weaned off cardiopulmonary bypass.
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INTRODUCTION
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Aortic valve replacement is a very common operation performed worldwide. It is usually safe and is generally a straightforward procedure. We report in a patient undergoing valve replacement an unusual coronary anatomy hitherto undescribed to the best of our knowledge. We hope to shed some light on this uncommon anatomy and the operative complications that may be encountered.
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CASE REPORT
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A 22-year-old male with rheumatic aortic regurgitation, who was otherwise healthy with no history of diabetes or hypertension, was referred for evaluation. The symptoms presented were palpitation, dyspnea, and atypical chest pain. The electrocardiogram was consistent with left ventricular (LV) hypertrophy. Chest radiography revealed cardiomegaly with LV configuration. Echocardiography showed a dilated left ventricle with good systolic function, a thickened aortic valve, and LV internal diameter of 6 cm in diastole and 4 cm in systole. Doppler assessment showed severe aortic regurgitation and mild mitral regurgitation. Cardiac catheterization was not performed.
A standard median sternotomy was performed on cardiopulmonary bypass (CPB), with antegrade cold blood cardioplegia and systemic cooling to 25°C. Upon opening the aortic root, it was evident that the left coronary artery arose from the noncoronary cusp area in close proximity to the aortic annulus (Figure 1
). The right coronary ostium had a normal origin. The aortic valve was grossly abnormal with rolled-in and thickened edges and was clearly incompetent. Aortic valve replacement with a 23-mm Carbomedics valve (Sulzer Medica, Winterthur, Switzerland) was carried out with care not to compromise the left coronary ostium and keeping the pledgets out of the way. The valve was fixed in place using 2/0 pledget-supported Ticron suture (Davis & Geck, Wayne, NJ, USA) on the aortic side. After closure of the aortotomy and deairing, the aortic crossclamp was removed and heart beats resumed. There was some widening of the QRS complex and evidence of ST segment elevation. This change persisted and it became apparent that the left ventricle was not moving well in the anterolateral area.
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Figure 1. Schematic representation of the aberrant coronary artery. CX = circumflex artery, L = left aortic sinus, LAD = left anterior descending artery, N = noncoronary sinus, R = right aortic sinus, RCA = right coronary artery, RV = right ventricle.
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A compromised left coronary ostium was felt to be the likely cause. A Teflon pledget was thought to be partially obstructing it. CPB was reinstituted; the aortic root was reopened and inspected. The left coronary ostium was found to be patent. There was, however, some question about the proximity of a pledget and so it was removed. CPB was terminated and the patient remained stable for a short while, but the old picture reemerged of ST segment elevation and evidence of LV dysfunction. It was decided then to go back on CPB and to perform bypass grafting to the affected coronary system. Upon examination, the circumflex artery was found to be very small. We therefore grafted the left anterior descending artery (LAD) with a reversed saphenous vein graft (SVG) on beating heart. CPB was discontinued and the patient was weaned off without problem and with good hemodynamics. As the myocardium might have been subjected to considerable insult, an intraaortic balloon pump was inserted to help the heart for the first few hours postoperatively. The balloon pump was removed the following morning. The patient continued to maintain excellent hemodynamic performance.
The postoperative course was uneventful and the patient was discharged on the 10th postoperative day. He had been followed for more than a year without any problems. On his last visit, he underwent elective cardiac catheterization to assess the status of the SVG (Figure 2).
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DISCUSSION
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Aortic valve replacement is a routine cardiac operation with a usually favorable outcome. Normally, the left coronary ostium opens in the left coronary cusp 0.5 to 1.5 cm superior to the aortic annulus,1 which leaves sufficient space for a prosthesis to be placed and sutured without obstructing the orifice.2 In this patient, there were 2 anomalies. The first one was the origin of the left coronary artery from the noncoronary cusp, resulting in the artery extending posteriorly to the aortic annulus for some distance before it bifurcates. This is a rare anomaly.3–5 In such a case, the aortic valve prosthesis may partially obstruct the left main stem because of compression of the artery by the sewing ring of the prosthesis. The second was the close proximity of the left coronary ostium to the aortic annulus. To our knowledge, this anomaly has not been described in the literature. In this situation, the cuff of the sewing ring will cause partial or complete obstruction of the coronary ostium. Thus, it would probably be wise to put the Teflon pledget on the ventricular side, and a smaller valve may also help. Ideally, if the situation calls for coronary artery bypass grafting, then full revascularization of the left coronary system is needed, preferably utilizing the left internal mammary artery (LIMA) for the LAD and also grafting of the circumflex.
In this particular patient, however, because of the urgency and a small circumflex artery, we opted for a reversed SVG to the LAD. Very close follow-up for this patient is needed because the long-term patency of the reversed SVG is much inferior to that of the LIMA.
In conclusion, when LV failure occurs unexpectedly during an aortic valve procedure and does not improve with reperfusion, a mechanical problem in the left coronary artery should be considered. In such a situation, we recommend that the left coronary system be bypassed utilizing the LIMA as one of the conduits.
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REFERENCES
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- Moore KL. Thorax. In: Clinically oriented anatomy. Baltimore: Williams & Wilkins, 1980:1–120.
- Kirklin JW, Barratt-Boyes BG. Aortic valve disease. In: Cardiac surgery. 2nd ed. New York: Churchill Livingstone, 1993:491–571.
- Lawson MA, Dailey SM, Soto B. Selective injection of a left coronary artery arising anomalously from the posterior aortic sinus. Cathet Cardiovasc Diagn
1993;30:300–2.[Medline]
- Kaku B, Shimizu M, Yoshio H, Ino H, Mizuno S, Kanaya H, et al. Clinical features of prognosis of Japanese patients with anomalous origin of the coronary artery. Jpn Circ J
1996;60:731–41.[Medline]
- Lo PH, Chang KC, Hung JS, Chen HL, Fang CY, Fu M, et al. Anomalous origin of left main coronary artery from the noncoronary sinus: an intravascular ultrasound observation. Cathet Cardiovasc Diagn
1997;42:430–3.[Medline]
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ABSTRACT
INTRODUCTION
