Journal of Cardiac Surgery | 2021
Should we ignore asymptomatic anomalous coronary arteries in patients presenting for aortic valve replacement?
Abstract
Individualized treatment strategies are unpopular in surgical interventions, as the general agreement is, that standardized approaches are more likely to achieve higher quality standards. On the other hand, clinical findings that we are seldomly confronted with, often require such an individualized solution that considers the relative risk of the problem at hand. In this context, one must point out, that individualized solutions, do not rule out but rather emphasize the need for meticulous preoperative planning, to balance out the relative merits of the different options. The case report by Maximo et al. is a good example of such a well‐planned individualized approach for a seldomly encountered surgical problem. Namely an anomalous origin of a circumflex artery from the right coronary sinus. Coronary artery anomalies are a diverse group of congenital disorders whose manifestations and pathophysiological mechanisms are highly variable. Yamanaka and Hobbs described their incidence with 1.3% among 126,595 patients undergoing coronary angiography for suspected coronary ischemia while Naito et al. described a prevalence of 4% among 1099 consecutive patients who received coronary evaluation before elective aortic valve surgery. Anomalous coronary arteries vary not only in their origin but also in their course. Their clinical implications can be quite serious being an important cause of sudden cardiac death among athletes and other young adults with otherwise unknown health problems furthermore, they are a potential cause for malignant arrhythmias, myocardial ischemia, and myocardial dysfunction. An intramural, as well as an interarterial course, are often described as significant risk factors for an unfavorable prognosis. Owing to their diversity, different surgical options exist, when dealing with aberrant coronaries. These include unroofing of an intramural segment, osteoplasty, transposition of the ectopic artery, or bypass grafting. An essential tool for proper assessment and planning is a three‐dimensional computed tomographic reconstruction angiography. 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. Alameddine et al. 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. In most patients the aberrant vessel was not mobilized, in two patients the vessel was bypassed. Interestingly, two patients were treated with a transcatheter aortic valve replacement (TAVR) because of multiple morbidities with high operative risk, both had tricuspid valves and an uneventful postoperative course. In a retrospective study comprising a total of 1099 consecutive patients undergoing elective aortic valve surgery and preoperative coronary evaluation, Naito et al. identified 46 patients (4%) with coronary anomalies, with a significantly higher incidence among patients with a BAV (7% vs. 3%; p = .001). Furthermore, they reported that myocardial enzymes as well as the need for postoperative coronary angiography/interventions were significantly higher in patients with coronary anomalies (12% vs. 1%, p < .001). Interestingly they pointed out that the coronary abnormalities they encountered were not surgically corrected unless reimplantation was needed for a root replacement. In a case series of six patients presenting for aortic valve surgery with a concomitant anomalous left circumflex artery (LCX). Liebrich