Author + information
- Paolo Angelini, MD⁎ ()
- ↵⁎Texas Heart Institute at St. Luke's Episcopal Hospital, 6624 Fannin Street, Suite 2780, Houston, Texas 77030
I read with great interest the paper by Eshelbrenner et al. (1) about the exceptional occurrence of 2 coronary anomalies in the same patient, jointly with a coronary complication of mitral valve surgery. The case report's exquisite images are unique and prompt a potentially important point the authors did not make. Although the congenital anomalous origin of the circumflex (Cx) from the right coronary artery (RCA) with a retroaortic course did not by itself have any clinical effect before surgery, accidental Cx ligation occurred during mitral valve annuloplasty. Figure 2 of the Eshelbrenner et al. paper (1) illustrates quite vividly the excellent collaterals that developed over the post-operative years (end-to-end anastomosis from the RCA to the Cx). De novo angina and a positive nuclear stress test at the posterolateral territory in this context must have been mainly caused by the proximal ectopic RCA. Such a vessel indeed originated from the left sinus of Valsalva, probably with a stenotic proximal trunk, that coursed inside the aortic wall, and not “between aorta and pulmonary artery” as is frequently stated (this proximal stenosis apparently was also suggested by angiography). As recently shown by intravascular ultrasound imaging, all cases of ectopic RCA have some degree of stenosis by lateral compression and hypoplasia (2). Such stenosis was the ultimate cause of limited blood flow in the present case because the RCA became the supplier of both the RCA and the Cx territories. This caused the equivalent of significant left main trunk stenosis.
In the post-operative state, after the brilliant initial results of Cx stent angioplasty, the proximal RCA could be a residual or recurrent problem. Specifically, one should be aware that, especially in case of restenosis (likely at an increased risk in this case because a bare-metal stent was used to treat a Cx lesion caused by surgical stitch ligation), symptoms equivalent to those of left main stenosis could recur.
- American College of Cardiology Foundation