Abstract Rationale Anomalous aortic origin of the left coronary artery from the right sinus of Valsalva (AAOCA-L) is a rare congenital anomaly, with a prevalence of approximately 0.03-0.05% in angiographic or coronary CT studies. While often diagnosed incidentally in young individuals, late discovery in older adults poses unique anesthetic and surgical challenges, especially during cardiac surgery requiring cardiopulmonary bypass. This report describes the perioperative anesthetic management of an adult patient with bicuspid aortic valve stenosis and hypoplastic left main coronary artery arising anomalously from the right sinus of Valsalva. Methods A 62 year old man with dyslipidemia, bicuspid aortic valve with moderate to severe stenosis, and no history of allergies or transfusions was scheduled for elective biological aortic valve replacement (Inspiris #25) and double arterial coronary revascularization. His medications included acetylsalicylic acid, rosuvastatin, and evolocumab. Preoperative stress echocardiography demonstrated inducible ischemia with hypotension (80/40 mmHg) and ECG evidence of subendocardial ischemia. Coronary CT revealed a calcium score of 917, non significant (50%) stenosis, and hypoplastic left main coronary artery with anomalous origin from the right sinus of Valsalva, confirmed by angiography. The patient was classified as ASA III with high cardiovascular risk. Balanced general anesthesia was induced with propofol, target-controlled fentanyl, and rocuronium, followed by maintenance using total intravenous anesthesia (propofol and fentanyl under TCI). Multimodal invasive monitoring included a brachial arterial line and central venous catheter. Cardiopulmonary bypass lasted 108 minutes (aortic cross-clamp 96 minutes). Hemodynamic targets focused on maintaining mean arterial pressure 70 mmHg, optimizing preload and afterload, and minimizing myocardial oxygen demand. Vasoactive support included norepinephrine (0.03-0.05 µg/kg/min) and dobutamine (2 µg/kg/min). Heparin reversal and fluid balance were carefully controlled. Results Intraoperative hemodynamic stability was achieved without ischemic episodes. Postoperative evolution was favorable, with early extubation and no signs of myocardial ischemia or low-output syndrome. The patient was transferred to the intensive care unit for continued optimization and recovered uneventfully. Conclusion AAOCA-L represents a rare but clinically significant challenge for the anesthesiologist, requiring vigilant intraoperative management and precise hemodynamic control. This case underscores the importance of preoperative anatomical recognition, real-time monitoring, and multidisciplinary coordination in mitigating ischemic risk and achieving safe outcomes in adult cardiac surgery with congenital coronary anomalies. This abstract is funded by: None
Morales et al. (Fri,) studied this question.