[Lack of left main and the operation of aortic valve replacement].

Heart valve surgery demands cardiac arrest with concomitant cardiac protection against ischaemia and reperfusion. Anomalous origin of left coronary artery (LCA) system require different approach to the infusion of cardioplegia into coronary ostia. We present a case of a patient suffering from severe aortic stenosis with concomitant aortic insufficiency and double ostium LCA with left artery descending and circumflex arteries originating separately from the left sinus of Valslava. During the procedure a retrograde, intermittent, cold-crystalloid cardioplegia was applied with moderate hypothermic arrest of 32°C. Antegrade cardioplegia in patients presenting with anomalous origin of left coronary system when direct coronary intubation is required remains controversial. In such cases retrograde cardioplegia serves a valid option for the operating surgeon.