Ann Thorac Surg 2007;83:1867-1869
© 2007 The Society of Thoracic Surgeons
Case Reports
Right Coronary Artery With High Takeoff
Arif Tarhan, MD*,
Tamer Kehlibar, MD,
Mehmet Yilmaz, MD,
Yucesin Arslan, MD,
Cansin Pancaroglu, MD,
Sinem Yigit, MD,
Azmi Ozler, Asc Prof
Department of Cardiovascular Surgery, Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
Accepted for publication November 9, 2006.
* Address correspondence to Dr Tarhan, Hizirbey Caddesi Nesrin Sokak No: 1 D: 11 Göztepe, Istanbul 34732 Turkey (Email: atarhan{at}gmail.com).
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Abstract
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Anomalous origin of the right coronary artery is an extremely rare anomaly. We describe the case of a patient whose right coronary artery was arising from the ascending aorta with high takeoff. We diagnosed the anomaly incidentally during the operation. After transverse aortotomy for aortic valve replacement, we recognized the transection of the right coronary artery. The right coronary artery ostium was located approximately 5 cm above the right sinus of Valsalva. It was showing a complete transmural course. We repaired the right coronary artery by bypassing it with a saphenous vein graft.
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Introduction
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Anomalous origin of the right coronary artery (RCA) is an extremely rare anomaly. We describe the case of a patient whose RCA was arising from the ascending aorta approximately 5 cm above the right sinus and following a transmural course. This patient is unique, because we believe there is no such other case in the literature whose RCA was originating from the ascending aorta with high takeoff. The majority of cases had an anomalous RCA that was arising from nearby to the left sinus valsalva [1].
A 72-year-old man was referred to the hospital for aortic valve replacement. He had symptoms of fatigue and exertional dyspnea. Physical examination revealed a systolic murmur. An electrocardiogram revealed sinus rhythm and blood chemistry data that were in normal ranges. Transthoracic echocardiography revealed calcified bicuspid aortic valve stenosis, left ventricular hypertrophy, and an enlarged left ventricular chamber. Left ventricular function was normal (ejection fraction, 0.61). Cardiac catheterization confirmed the diagnosis of calcified aortic stenosis with an orifice area of 0.72 cm2 and a maximal systolic gradient of 123 mm Hg.
A coronary angiography revealed 30% stenosis in the proximal portion of the left anterior descending coronary artery and normal left circumflex artery. The RCA was not located in its usual location. It was documented as a ghost-like image in an aortogram (Fig 1).
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Fig 1. Preoperative angiogram of an anomalous right coronary artery. Aortic root injection shows a ghost-like image of the abnormal route of the right coronary artery (arrows).
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Surgery was performed by a standard median sternotomy. After the patient was cooled down to 28°C, the aorta was clamped. The initial dose of blood cardioplegia (10 mL/kg) was given into the aortic root; then the aorta was exposed through a standard transverse aortotomy, 2 cm above the expected RCA orifice.
The RCA was originating from the anterior surface of the ascending aorta, 5 cm above its expected and usual location, showing a transmural course that was discontinued by the aortatomy incision.
The diseased aortic valve was excised and replaced with a St. Jude Medical Masters Series Mechanical Heart Valve, no. 23 (St. Jude Medical Inc, Minneapolis, MN). The saphenous vein graft was anastomosed to the RCA. The patient’s postoperative course was uneventful. A postoperative coronary angiography revealed a patent saphenous graft. At postoperative month 18 the patient remains symptom free.
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Comment
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An anomalous origin of RCA may be asymptomatic, and an incidental finding at autopsy may present with sudden death, evidence of myocardial ischemia, or syncope. The frequency of anomalous origin of the RCA in the adult population is rare and it is found between 0.019% and 0.17% of autopsies [1].
The most emphasized anomaly of the RCA in literature is takeoff from the wrong coronary sinus. Congenitally bicuspid aortic valve may accompany the malformation [2]. In our case, the RCA originated from the anterior surface of the ascending aorta, high above the right sinus. We recognized two other similar cases whose RCAs originated from the tubular portion of the ascending aorta [3, 4], but the orifices were not so far away from the sinuses as they were in our patient.
During the examination, the RCA ostium was not detected at its usual location on the right aortic sinus. An unusual dehiscence was noticed over the aortic incision line (Fig 2A). It was supposed to be an aortic tear in the incision line due to inappropriate instrumentation, but after further detailed examination the hole was determined to be the cross-section of a transected RCA. The RCA orifice was in the ascending aorta, surprisingly 5 cm above its usual location, and the RCA was showing a transmural course (Fig 2B). Coronary angiography can identify the anomalous origin of the coronary artery, but the course of the anomalous artery and the relationship to the right ventricular outflow tract can be difficult to determine [5]. In such situations in which the coronary artery orifice is undetermined in angiography, magnetic resonance imaging may be useful to localize the orifice and the pathway of the coronary artery.
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Fig 2. (A) Operational picture of discontinuation of anomalous right coronary artery. (B) Illustration of anomalous right coronary artery.
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After the diagnosis of the coronary abnormality due to unavoidable transsection of its tunnel portion, we scrutinized repairing alternatives (ie, direct coronary reimplantation [5, 6], unroofing [7], or saphenous bypass [8]). In our case, the aortic tunnel portion of the RCA was too long to excise and reimplant. If we preferred to excise the coronary tunnel from the aorta, we had to replace the ascending aorta. If we had preferred to unroof the intramural segment, the aortic wall might have been weakened. We selected a basic method (ie, the saphenous vein graft bypass) to repair the discontinuation of the RCA.
In conclusion, angiographic recognition of anomalous vessels is important because of their clinical significance and importance in patients undergoing cardiac surgery. Absence of the RCA in a coronary angiogram may suggest the possibility of a coronary anomaly, especially when main branches can not be opacified by selective contrast medium injection.
Saphenous vein bypass can be performed safely to repair the RCA with high takeoff.
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References
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- Kragel AH, Roberts WC. Anomalous origin of either the right or left main coronary artery from the aorta with subsequent coursing between aorta and pulmonary trunk: analysis of 32 necropsy cases Am J Cardiol 1988;62:771-777.[Medline]
- Chadow H, Kwan T, Huber M, Feit A. Anomalous origin of the right coronary artery above the left posterior sinus of Valsalva associated with a normal aortic valveA case history. Angiology 1994;45:963-966.[Medline]
- Alpaslan M, Onrat E. Anomalaous origin of right coronary artery above the sinus of Valsalva: observation by transthoracic echocardiography J Am Soc Echocardiogr 2002;15:264-266.[Medline]
- Rotge PP, Ferrando NA, Sahagun NB, Herrero SM, Capmany RP. Right coronary artery with anomalous pathway and myocardial ischemia Rev Esp Cardiol 1999;52:1154-1156.[Medline]
- Rogers Jr SO, Leacche M, Mihaljevic T, Rawn JD, Byrne JG. Surgery for anomalous origin of the right coronary artery from the left aortic sinus Ann Thorac Surg 2004;78:1829-1831.[Abstract/Free Full Text]
- Furukawa K, Itoh T. Direct coronary reimplantation for repair of anomalous aortic origin of left or right coronary artery Ann Thorac Surg 2003;76:589-595discussion 595–6.[Abstract/Free Full Text]
- Romp RL, Herlong JR, Landolfo CK, et al. Outcome of unroofing procedure for repair of anomalous aortic origin of left or right coronary artery Ann Thorac Surg 2003;76:589-596.[Abstract/Free Full Text]
- Bett JH, O’Brien MF, Murray PJ. Surgery for anomalous origin of the right coronary artery Br Heart J 1985;53:459-461.[Abstract/Free Full Text]
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Abstract
Introduction
