The left internal thoracic artery to bypass an abnormal circumflex artery arising from the right coronary sinus in a patient scheduled for root aneurysm

Although classic valve-sparing root repair yields excellent results (survival at 10 years of 93.5%, freedom from structural valve deterioration at 10 years of 96.1% [1]), I agree with Siepe and colleagues [2] that extensive skeletonization of the aortic root might jeopardize an abnormal circumflex artery arising from the right coronary sinus and crossing the dorsal aspect of the annulus. I also agree with the authors’ suggestion that prosthetic valve and root replacement (Bentall procedure) with reimplantation of all three ostia is a possibly dangerous procedure due to potential distorsion of the circumflex artery during suture and prosthesis placement. On the other hand, the left internal thoracic artery (LITA) graft has excellent long-term patency when grafted to the circumflex coronary artery (almost 90% at 10 years [3]). Therefore, in my opinion, the ostium of the abnormal circumflex artery should be oversewn, and the in situ LITA graft (skeletonized or pedicled) should be used to bypass the circumflex artery (if possible, the circumflex artery should also be ligated and oversewn proximal to the anastomotic site). The oversewing of an abnormal circumflex coronary artery ostium originating from the right coronary sinus in close proximity to the commissure between the nonand the right-coronary sinus could jeopardize annular geometry and outcome of valve sparing root repair procedure. Therefore, my final choice would be to perform prosthetic valve and root replacement (Bentall ’button’ procedure) with reimplantation of the right and left coronary ostia. The ostium of the abnormal circumflex artery should be oversewn, and the LITA conduit should be used to graft the circumflex coronary artery. This approach can make the whole procedure very safe and simple.