Right coronary ostial transection during aortic valve replacement: technique of reconstruction

Abstract

A 24 year old male patient was admitted with a diagnosis of bicuspid aortic valve with severe aortic stenosis and an aortic root size of 23 mm. He was scheduled to undergo aortic valve replacement using the pulmonary autograft (Ross procedure). At operation, there were dense pericardial adhesions all around the heart rendering the cardiac anatomy obscure. There was suspicion of rheumatic pathology, so the Ross procedure was abandoned and instead prosthetic valve replacement of the aortic valve was planned. Standard normothermic cardiopulmonary bypass was established and the aorta was cross clamped. An oblique aortotomy is usually performed at least 1 cm above the right coronary ostium and this extends in an oblique fashion into the non-coronary sinus. Because of the dense adhesions, the right coronary origin was not clearly visualized and appeared to be located more cranially than normal. After aortotomy, we observed that the right coronary ostium had been completely transected. The proximal part had come in the upper lip of the aortotomy as a blind cul de sac and the opening was seen in the wall of the aorta close to the lower lip of the aortotomy. Upon passing a 2.5 mm probe through this opening, it was found to be in the right coronary artery, whose proximal part was intramural and running more obliquely than the usual course (Fig. 1). The left coronary artery ostium was normally placed. Direct ostial cardioplegia was delivered to both the coronary arteries.