Anomalous circumflex artery encircling the aortic annulus: implications for mitral valve repair

Abstract

Injury to coronary arteries during mitral surgery is a rare but life-threatening procedural complication, an anomalous origin and course of the left circumflex artery (LCx) increase this risk. Recognizing the anomaly by the characteristic angiographic pattern and identifying its relationship with the surrounding anatomical structure using imaging techniques, mainly transesophageal echocardiography (TOE) or coronary computed tomography angiography (CCTA), is of crucial importance in setting up the best surgical strategy. We report a case of anomalous origin of a circumflex artery (LCx) from the proximal portion of the right coronary artery (RCA) with a pathway running retroaortically through the mitro-aortic space. An integrated diagnostic approach using a multidisciplinary team with a cardiologist and an imaging radiologist allowed us to decide the surgical strategy. We successfully performed a mitral valvular repair using a minimally invasive minithoracotomic approach and implanting a complete semirigid ring.

Keywords: Anomalous circumflex coronary course; Coronary injury; Intraoperative complication; Mitral valve surgery.

Fig. 1

Coronary angiogram (LAO with Cranial 30°) shows the origin (1A), the middle (2A) and the distal portion (3^a) of the anomalous circumflex artery

Fig. 2

TOE long axis shows the hinge point of the anterior mitral leaflet (H.P.) and the anomalous circumflex artery (C.A.) (2A) and the distance between this two points. 2B shows the same projection in 3D. CxA (anomalous circumflex artery); HP (hinge point of the anterior mitral leaflet); AL (Anterior leaflet). IMG 2 C- 2 D The CCTA study confirmed the anomalous origin of a circumflex artery (LCx) from the proximal portion of the right coronary artery (RCA) with a pathway running retroaortically through the mitro-aortic space

Fig. 3

3D TOE shows the postoperative 3D view