Alternative myocardial protection strategies are necessary in patients with intramural aortic course of anomalous coronary artery.

A 48-year old Caucasian woman presented with chest pain on exertion and was diagnosed with an anomalous origin of dominant right coronary artery, it then ran a short intramural course in the wall of the aorta. Right coronary artery (RCA) was reimplanted on cardiac bypass at normal exit point on the aortic root. The heart was adequately protected with antegrade cold blood cardioplegia via the aortic root and regular direct cardioplegia via the coronary ostia. The patient could not come off cardiopulmonary bypass after surgery and required right ventricular assist device support to be weaned from cardiopulmonary bypass. The patient ultimately recovered well and her right heart function is normalising. We believe that antegrade cardioplegia via the aortic root caused increased pressure in the aorta and squashed RCA in the wall of the aorta causing failure of myocardial protection and stunning of the right ventricle. This could be prevented with alternative myocardial protection strategies like direct cardioplegia via the coronary ostium.