Cardiopulmonary bypass weaning difficulty due to anomalous origin of coronary artery -A case report-
A 76-year-old male with 160 cm in height and 58 kg in weight, respectively, was admitted for surgery with known aortic stenosis. He has a previous history of diabetes, hypertension and asthma. He had taken glimepiride, telmisartan, furosemide and bisoprolol. Preoperative echocardiography exams revealed the followings: aortic valve calcification and severe stenosis, a decreased left ventricular systolic function, trivial tricuspid regurgitation and ejection fraction of 40-45%. In a coronary artery angiography, right coronary artery was originated from the left coronary sinus (). However, compression of the coronary arteries by major vessels was not revealed. Coronary computed tomography (CT) was not checked. The patient was scheduled for aortic valve replacement.\nAt the operating theatre, routine noninvasive and invasive blood pressure monitoring, electrocardiography (EKG), pulse oximetry and bispectral index monitoring was established. Anesthetic induction was done under target-controlled infusion (TCI) of propofol and remifentanil. Then pulmonary artery catheter and transesophageal echocardiography (TEE) probe were inserted. TEE revealed severe calcified and stenotic aortic valve, trivial tricuspid regurgitation and a good regional wall motion. Until the CPB initiation, vital signs were maintained well.\nAt the time of the operation, aortic valve and annulus were severely calcified and both coronary arteries were originated from the left coronary sinus, but have different ostia. Aortic valve was replaced with 19 mm St. Jude Medical xenoartic bioprosthesis Epic (St. Jude Medical, Minnesota, USA) and the surgery were done without specific event. During cardiopulmonary bypass weaning, blood pressure and cardiac output were unstable. The changes of ST segment in EKG were detected. These situations were repeated for about 30 minutes, and dopamine and norepinephrine infusion were started. TEE showed intermittent hypokinesia of inferoposterior wall motion. Air was not detected, and nitroglycerin infusion was not effective. Epinephrine was infused and intraaortic balloon pump (IABP) was inserted. Cardiac wall motion was progressively normalized and vital signs were stabilized. The total surgery and CPB time was 360 minutes and 161 minutes, respectively. The patient was transferred to coronary care unit after surgery, and vital signs were also stable. Anomalous origin of the right coronary was considered as the culprit for the difficult weaning process. IABP was removed the next day, and the patient was discharged without any special events.