Unexpected Coronary Malperfusion Requiring Bailout Coronary Artery Bypass Grafting after Valve-Sparing Aortic Root Replacement in a Patient with Anomalous Aortic Origin of a Coronary Artery: A Case Report.

Valve-sparing aortic root replacement (VSRR) requires coronary button reimplantation, and anomalous coronary anatomy may increase the risk of unexpected coronary malperfusion. A 38-year-old man with Marfan syndrome underwent VSRR for aortic root aneurysm and severe aortic regurgitation. The right coronary artery arose anomalously from the left sinus of Valsalva. Despite apparently satisfactory reconstruction, severe myocardial ischemia developed after coronary reimplantation during weaning from cardiopulmonary bypass. Intraoperative reassessment revealed no obvious kinking or obstruction of the right coronary artery, and bougie passage confirmed luminal patency. Because the mechanism of malperfusion remained unclear, bailout coronary artery bypass grafting (CABG) was performed. Hemodynamics stabilized promptly, and postoperative imaging confirmed graft patency. Geometric alteration of a reimplanted coronary artery may result in dynamic malperfusion even when reconstruction appears technically satisfactory. When persistent ischemia occurs without an identifiable anatomical cause, early bailout CABG may provide a practical treatment option.