Navigating coronary anomalies: myocardial protection during cardiac surgery with a single coronary ostium

Background: In the setting of aortic valve surgery and concomitant coronary artery disease, an anomalous right coronary artery necessitates meticulous planning of cardioplegia delivery and myocardial protection strategies. Case report: We present a 75-year-old man undergoing aortic valve replacement and coronary artery bypass grafting. He had a known anomalous right coronary artery arising from the left sinus of Valsalva. The co-dominant right coronary also had an interaarterial course. This made grafting to the diseased anomalous right coronary impossible. In addition, the angle of take-off from the left ostia made the right coronary prone to compression and stenosis during delivery of plegia, hence more important to ensure its patency for adequate perfusion of cardioplegia to the inferior territory of the heart. Discussion: Preoperative planning was crucial to inform intraoperative myocardial protection strategy, including fibrillation of the heart after cross clamping to prevent ventricular dilatation, adequate drainage of the left ventricle using a vent, and central as well as topical cooling but most importantly ensuring optimal reduction of myocardial metabolic rate by delivery of cardioplegia to both right and left system. In this case selective cannulation of each coronary was not possible due to a tight common ostium. We will discuss whether a deroofing procedure could have been considered. Conclusion: We highlight the value of an individualised myocardial protection strategy for patients with complex coronary anomalies, as conventional antegrade cardioplegia delivery may be inadequate or potentially hazardous due to the complex anatomy associated with an anomalous coronary origin.