Anomalous Left Circumflex Artery in Valve Interventions: Surgical and Transcatheter Challenges

Area of Science:

• Cardiovascular Surgery
• Interventional Cardiology
• Cardiac Anatomy

Background:

• Anomalous origin of the left circumflex coronary artery (AOLCX) with a retro-aortic course poses a risk during valve interventions.
• Iatrogenic injury, though typically benign, can lead to severe ischemia, necessitating careful management.
• Expanding transcatheter aortic valve replacement (TAVR) use in lower-risk patients highlights the need to understand injury mechanisms in both surgical and TAVR settings.

Purpose of the Study:

• To review anatomical risks, injury mechanisms, and management strategies for AOLCX during valve interventions.
• To synthesize evidence from surgical and transcatheter procedures to inform clinical practice.
• To emphasize the importance of pre-procedural assessment and tailored preventive measures.

Main Methods:

• A narrative review of 45 relevant publications was conducted.
• Focus was placed on anatomical considerations, mechanisms of injury, and treatment options for AOLCX.
• Integration of technical and anatomical evidence from the literature.

Main Results:

• Left circumflex artery compromise depends on its proximity to the aortic and mitral annuli.
• Surgical injury is often caused by deep sutures or prosthetic rings; TAVR injury involves retro-aortic compression or ostial occlusion.
• Pre-procedural assessment (coronary height, sinus dimensions, calcification, annular proximity) and preventive strategies (mobilization, bypass, guidewire protection) are vital.

Conclusions:

• Pre-procedural computed tomography angiography is essential for quantifying anatomical risk.
• A Heart Team approach is required for optimal intervention selection and mechanism-specific protection.
• Long-term clinical and imaging surveillance is necessary to prevent acute and delayed AOLCX compromise.