Surgical management of a patient with anomalous origin of the left circumflex coronary artery undergoing aortic and mitral valve surgery

Abstract

Background: The anomalous origin of the left circumflex coronary artery is rare and, when isolated, typically has minimal pathological significance. However, it can cause damage or compression of the coronary artery during aortic and mitral valve surgery.

Case presentation: The patient was a 34-year-old male diagnosed with severe aortic regurgitation due to a bicuspid aortic valve following infective endocarditis at the mitral valve. He was referred to our hospital owing to worsening heart failure. Preoperative evaluation revealed a mitral valve aneurysm and an anomalous left circumflex coronary artery originating from the right coronary artery and running posteriorly along the aortic valve annulus. During surgery, dissection of the anomalous left circumflex coronary artery was challenging. Mitral valve aneurysm repair and aortic valve replacement were performed. For the aortic valve replacement, a 23-mm St. Jude Medical Regent valve, one size smaller than optimal, was secured in the supra-annular position. Additionally, a coronary artery bypass graft was performed on the distal circumflex artery using a saphenous vein graft. The patient experienced no ischemic myocardial damage and was discharged in stable condition on postoperative day 14.

Conclusions: The anomalous origin of the left circumflex coronary artery should be recognized, and appropriate measures must be taken during valve surgery. Preemptive coronary artery bypass grafting is a reasonable option for patients undergoing aortic and mitral valve surgeries.

Keywords: Anomalous origin of the coronary artery; Anomalous origin of the left circumflex coronary artery; Bicuspid aortic valve; Coronary artery bypass grafting; Valve surgery.

Fig. 1

Transthoracic echocardiograms showing severe eccentric aortic regurgitation (a) and an anterior mitral valve leaflet aneurysm (white arrow) (b)

Fig. 2

Transesophageal echocardiograms showing a Sievers Type I bicuspid aortic valve with fused left and right coronary cusps and aortic regurgitation (a) and an approximately 1.2-cm aneurysm of the anterior mitral valve leaflet (white arrow) (b and c)

Fig. 3

Coronary angiogram showing the left circumflex coronary artery arising near the origin of the right coronary artery (white arrow)

Fig. 4

Preoperative computed tomography showing that the left circumflex coronary artery (white arrow) originated from the right coronary artery (a and b). It traversed the commissures of the right and noncoronary cusps of the aortic valve (white arrowhead) (b) and extended between the aorta and the right and left atria (a and b). The artery then continued to the right fibrous trigone (blue arrowhead), reaching the posterior atrioventricular groove (a). Between the aorta and the left atrium, it passed slightly above the aortic valve annulus (yellow arrowhead) and the mitral valve annulus (green arrowhead) (b and c). Additionally, an anterior mitral valve aneurysm (asterisk) was observed (c). LCA, left coronary artery; RCA, right coronary artery

Fig. 5

Postoperative computed tomography showing that the bypass graft (yellow arrow) to the obtuse marginal branch (white arrowhead) and anomalous left circumflex coronary artery (white arrow) were patent (a and b). The prosthetic valve (red arrowhead) and the anomalous left circumflex coronary artery (white dotted arrow) were positioned near each other at the posterior aspect of the aorta (c)