Introduction
Valve-sparing aortic root replacement (VSARR) has become a standard of
care for young patients with aortic root aneurysm.1 In
this procedure, coronary arteries are detached from the aortic wall and
reimplanted in their corresponding neosinuses. This approach may be
challenging in presence of congenital coronary artery disease, as
observed in about 1% of patients undergoing cardiac
catheterization.2 We report specific considerations
for VSARR related to the unusual association of aortic root aneurysm and
anomalous origin of the left circumflex artery (LCA).
Case description
A 45 year-old male patient presented for a dilated aortic root depicted
on a routine transthoracic echocardiography. The patient was
asymptomatic and physical examination was unremarkable. Chest CT imaging
confirmed the aortic aneurysm limited to the root with a maximal
diameter of 51 mm (29.4 mm/m²). An abnormal origin of the LCA emerging
from the right coronary sinus was remarkable. The aortic valve was
tricuspid with mild central regurgitation. Preoperative coronary
angiogram confirmed the aberrant origin of the LCA with a separate ostia
from the right coronary artery (RCA) (Figure 1 ). The proximal
segment of the LCA ran along the wall of the non-coronary sinus without
evidence for intramural course and joined the left atrial roof at the
level of the aortic annulus. The distal LCA thereafter reemerged in the
left atrioventricular groove (Figure 1 ). The anatomy of the RCA
and left anterior descending artery (LAD) was unremarkable. VSARR (David
procedure) was decided for this young patient who expected to perform
intensive physical activity. In the present case, the proximal
subannular suture line during the David procedure may lead to
irreversible injury of the retroaortic and subannular segment of
LCA.3 A coronary artery bypass grafting (CABG) of the
LCA combined with VSARR was therefore planned to secure the perfusion of
the left ventricular lateral wall.
After midline sternotomy, the left internal thoracic artery was
harvested as a skeletonized graft. Cardiopulmonary bypass (CPB) was then
established between the right atrium and the distal ascending aorta.
Myocardial protection was obtained by antegrade mild hypothermic (32˚C)
blood cardioplegia, repeated each 20 minutes. The aortic root was
carefully dissected and the location of the coronary ostia was
identified. The abnormal course of the LCA was isolated along the
non-coronary sinus, confirming the absence of intramural path at this
level (Figure 2 ). The dissection was conducted as low as
possible to prepare for the proximal suture line of the aortic graft at
the level of the ventriculo-aortic junction. The limit of the dissection
was the roof of the left atrium, where the LCA deeply engaged towards
the left atrioventricular groove. The CABG was then performed using the
left internal thoracic artery to the first obtuse marginal artery.
Afterwards, the aortic root was excised with preservation of two
coronary buttons, one for the left main and a larger one for both the
RCA and LCA ostia. The aortic valve was inspected and did not show any
anatomical contraindication for VSARR procedure. A 30-mm
gelatin-impregnated Valsalva prosthetic graft was first sutured using 9
interrupted U-stitches at the level of the ventriculo-aortic junction,
avoiding to damage the retro-aortic course of the LCA. The native aortic
valve was then included into the Valsalva tube using continuous running
sutures. Inspection of the re-implanted aortic valve showed favorable
leaflet coaptation (Figure 2 ). Reimplantation of coronary
buttons began with the left main using continuous running suture. The
coronary button including the RCA and LCA ostia was sutured to the right
coronary sinus of the Valsalva graft avoiding any malposition or kinking
of the proximal LCA. The peri-aortic course of the LCA was therefore
respected along the new non-coronary sinus (Figure 2 ). The
distal anastomosis between the Valsalva graft and the distal ascending
aorta was completed during warming. Sinus rhythm at 75 bpm recovered
spontaneously after aortic clamp release and CPB was weaned after 15
minutes of circulatory support. Aortic cross-clamping and CPB periods
were 182 and 202 minutes respectively. Transesophageal echocardiographic
examination showed satisfying aortic valve anatomy (effective height at
9 mm; coaptation length at 5 mm) without evidence for residual
regurgitation. Both ventricles presented with normal motion, especially
considering the left ventricular free wall.
Transient acute kidney injury related to hypovolemia was observed during
the early postoperative course. There was no evidence for myocardial
dysfunction, especially the echocardiography did not show abnormal
motion of the left ventricular wall. The postoperative coronary
angiogram showed normal LAD and RCA, as well as full patency of the LCA,
especially at the level of her retro-aortic course (Figure 2 ).
The patient recovered quickly from surgery and was able to resume
professional activity 6 weeks after hospital discharge.
Comment
The main insights of the present case report are threefold. First,
anatomical investigation of the coronary network is warranted before
aortic root surgery, even in young patients without cardiovascular
comorbidities. The association between aortic root aneurysm and coronary
anomalies is scarcely reported in the literature.4Anomalous origin and course of the LCA arising from the right coronary
sinus is observed in 0.37 to 0.7% of patients undergoing cardiac
catheterization.3,5 This anomaly has usually no
clinical significance but should be investigated before aortic root
surgery. The surgical procedure can therefore be planned to deal with
this aberrant anatomical configuration.2 Second, this
condition is challenging due to the peri-aortic and subannular course of
the LCA since VSARR requires extensive dissection of the aortic root as
low as possible. Moreover the David procedure needs sutures below the
aortic annulus and may therefore be at risk for perioperative coronary
injury in case of abnormal retro-aortic course of the LCA. The decision
to perform David procedure for VSARR rather than aortic root remodeling
was based on the better long-term outcomes associated with the
reimplantation approach. The Yacoub procedure does not require a
proximal suture line along the circumference of the ventriculo-aortic
junction but has been associated with a higher rate of late reoperation
(11% at 5 years) compared to the David procedure (<5% at 15
to 20 years).1,6 We therefore privileged the approach
associated with the better long-term outcomes for our young patient.
Last and consistent with Nezic et al., we suggested to perform a
preventional CABG to the distal LCA to secure the perfusion of the left
ventricular wall.7 This approach could also be applied
in case of retro-aortic and subannular course of the LCA in patients
referred for aortic valve replacement.8 Indeed all
sutures located along the aortic annulus below the left coronary sinus
could be at risk for LCA injury.
VSARR remains an effective option for aortic root aneurysm associated
with anomalous origin and course of the LCA. In our case, the ectopic
LCA was preserved without any iatrogenic damage after David procedure
for aortic root replacement.
Author contributions: JG: concept/desing/data
interpretation/drafting, RA: data interpretation/drafting the article,
MAI: data interpretation, PD: revision.