Low Origin of the Coronary Arteries and a Small Aortic Annulus Complicating Aortic Valve Replacement

Low origin of the coronary arteries, defined as an origin less than 10 mm above the functional aortic annulus, is not usually considered to be a notable anomaly because functional impairment is not intrinsic. We describe a case of severe complications after surgical aortic valve replacement in a 59-year-old woman who had symptomatic aortic valve stenosis, low origin of both main coronary arteries, and a hypoplastic aortic annulus less than 19 mm in diameter. The aortic prosthesis had to be implanted above the hypoplastic anatomic annulus. An inferior-wall myocardial infarction, hypotension, right-sided heart failure, and atrial fibrillation developed during the early perioperative period. Coronary angiograms showed occlusion of the right coronary artery ostium and critical stenosis of the left coronary ostium. During reoperation, posterior aortic patch annuloplasty enabled lower reimplantation of the prosthetic aortic valve, jointly with right coronary artery-venous grafting. To prevent potentially severe complications, we recommend that low origin of the coronary arteries be reported before patients undergo surgical aortic valve replacement. If the ostia are not seen when routine coronary angiography is used, computed tomography should be prospectively performed to characterize this anomaly.