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Surgical Aortic Valve Replacement in the Setting of Anomalous Circumflex Coronary Artery
Jobelle J R Baldonado1, Kevin L Greason1, Juan A Crestanello1
1Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
Insights
Surgical aortic valve replacement (SAVR) can cause injury to the anomalous circumflex coronary artery (ACCA), leading to myocardial ischemia in 16% of patients. Further research is needed to explore protective interventions for ACCA during SAVR.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Cardiac Imaging
Background:
- Anomalous circumflex coronary artery (ACCA) originates from the right coronary artery or sinus of Valsalva.
- ACCA proximity to the aortic valve annulus poses a risk during surgical aortic valve replacement (SAVR).
Purpose of the Study:
- To determine the prevalence of ACCA injury during SAVR.
- To assess the clinical impact of ACCA injury post-SAVR.
Main Methods:
- Retrospective review of 31 patients with ACCA undergoing SAVR at Mayo Clinic (2002-2018).
- Endpoint: myocardial ischemia in the ACCA distribution.
- Analysis of echocardiography and clinical outcomes.
Main Results:
- 16% of patients (5/31) showed echocardiographic evidence of myocardial ischemia in the ACCA territory.
- New lateral wall motion abnormality occurred in 16% of patients, with a significant reduction in ejection fraction.
- Coronary artery bypass graft to ACCA did not prevent new lateral wall motion abnormality.
Conclusions:
- SAVR is associated with a significant incidence of subclinical myocardial ischemia in patients with ACCA.
- Adjuvant interventions for ACCA may be beneficial and warrant further investigation.
- Long-term mortality was not associated with ACCA ischemia, but further study is needed.
Background:
The anomalous circumflex coronary artery (ACCA) from the right coronary artery or sinus of Valsalva lies in proximity to the aortic valve annulus. This study sought to determine the prevalence of injury to the ACCA during surgical aortic valve replacement (SAVR).
Methods:
We queried the databases of the Departments of Cardiovascular Surgery and Cardiovascular Diseases of Mayo Clinic, Rochester, Minnesota for all patients who underwent SAVR in the setting of an ACCA. The study investigators identified 31 patients operated on from September 2002 through December 2018. The end point was myocardial ischemia in the distribution of the ACCA.
Results:
The patients' mean age was 69 ± 11 years, sex was female in 8 patients (26%), and ejection fraction was 62% (interquartile range, 59% to 68%). No patient underwent exploration of the ACCA, but 5 (16%) had a coronary artery bypass graft to the ACCA. No patient demonstrated myocardial infarction or underwent perioperative intervention on the ACCA; however, discharge echocardiography showed new lateral wall motion abnormality in 5 (16%) patients that was associated with a reduction in ejection fraction of -11% from baseline (P = .007). Coronary artery bypass graft to the ACCA was not protective of new lateral wall motion abnormality (P = .968). Mortality was 34% ± 10% at 10 years and was not associated with new lateral wall motion abnormality (log-rank test P = .183).
Conclusions:
Clinically apparent myocardial infarction was not identified after SAVR, but echocardiographic evidence of myocardial ischemia in the distribution of the ACCA was identified in 16% of patients. Protective adjuvant intervention on the ACCA may be indicated. Further study is warranted.
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