Page 246 - Read Online

Salsano et al. Vessel Plus 2020;4:21 I http://dx.doi.org/10.20517/2574-1209.2020.12 Page 3 of 4

We marked the location of the bioprosthetic valve stent to avoid the left main lesion and/or mechanical
obstruction [Figure 1B]. The fibrous tissue around the ostium was deliberately left intact to avoid
inadvertent dissection [Figure 1B and C]. After valve implantation, the ascending aorta was replaced
with a 26 mm-Dacron Hemashield tube graft (Meadox Medicals, Inc., Oakland, New Jersey, N.J. USA).
2D-echocardiography showed good valve function postoperatively with no leak. The postoperative clinical
course was uneventful otherwise and no ischemic events occurred. At 6-month follow-up, the patient is
alive, asymptomatic and NYHA class I.

DISCUSSION
Our case included aortopathy and coronary anomaly in a patient with BAV. Coronary anomalies are rare
[10]
and are found in less than 1% of the general population . Their association with BAVs has been reported,
but there is a lack of focused studies in the literature to draw conclusions on detecting these anomalies
[11]
and the related operative risks . Interestingly, routine coronary angiography failed to detect the left main
coronary ostium origin anomaly. This is not completely unexpected since a high incidence of false negatives
[12]
has been reported when the anomaly involves the coronary origin . The location, orientation, height and
number of coronary ostia may necessitate different surgical approaches, not only during valve replacement
[13]
surgery, but during valve repair and valve sparing surgery too . During aortic valve replacement, it is
crucial to rotate the prosthesis so that the stent does not interfere with the anomalous coronary ostia. The
surgeon must be careful not to damage the coronary origin to avoid potentially catastrophic ischemic
events. In cases of intramural take off of the left coronary artery, as seen in our patient, the aortic root must
be manipulated with caution. If rotating the prosthesis is not sufficient to avoid the risk of ischemia, other
treatment options include unroofing the intramural segment, creation of a “neo-ostium” in the appropriate
sinus, reimplantation of the ostium, translocation of the pulmonary artery, and pericardial patching of
the aorta and proximal anomalous coronary artery [14,15] . Occasionally, coronary artery bypass grafting
is used but it is generally not recommended . We must be aware of coronary anomalies even during
[14]
aortic root surgery. Valve sparing surgery is feasible, although it may be necessary to associate it with
corrective surgery of the coronary anomaly. A careful surgical plan is mandatory for successful coronary
[16]
reimplantation and to avoid air embolism .
Despite being used off label with BAV, there are increasing numbers of Transcatheter Aortic Valve
Replacement procedures in the last few years . In view of the asymmetric nature of the BAV orifice
[9]
and heavy regional calcification, the risk of ischemia related to coronary anomalies during transcatheter
[17]
procedures is not negligible .
Unfortunately, there is a gap in knowledge such that we are not currently able to identify patients with
coronary anomalies and a high risk of ischemia, and to properly stratify the related surgical risk to the
correction of coronary anomalies .
[15]
Considering the potential issues, an accurate pre-operative diagnosis is crucial to avoid adverse outcomes.
Since routine angiography cannot be conclusive, as seen in our case, the use of gated coronary-CT, 3D
echocardiography or magnetic resonance imaging may be considered .
[18]
In conclusion, coronary anomalies may be associated with BAVs with potential implications for invasive
valve procedures. If underestimated or not recognized, coronary anomalies can lead to catastrophic
outcomes.

DECLARATIONS
Authors’ contributions
Made substantial contribution to the conception and design of the study, performed data analysis and data
interpretation: Salsano A, Ricci D, Santini F