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\begin{document}

\title{Utilization of Cardiac Graft with Single Coronary Artery for Orthotopic
Heart Transplantation}



\author[1]{Nicholas Hess}%
\author[2]{Mary Keebler}%
\author[3]{Carly A. Fabrizio}%
\author[1]{David Kaczorowski}%
\affil[1]{University of Pittsburgh Department of Cardiothoracic Surgery}%
\affil[2]{UPMC}%
\affil[3]{Christiana Care Health Services Inc}%


\vspace{-1em}



  
  \date{May 30, 2024}


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\selectlanguage{english}
\begin{abstract}
Anomalous coronary arteries arise in a small subset of the population,
with each configuration conveying a varying degree of long-term risk. In
this report, we describe the discovery of an anomalous single coronary
artery with the left main coronary artery arising from the right
coronary ostium in a 40-year old male evaluated for cardiac donation.
After evaluation, this heart was successfully procured and utilized for
orthotopic heart transplantation.%
\end{abstract}%



\sloppy


\emph{Introduction}

Coronary artery anomalies are uncommon, arising in approximately 0.1-5\%
of the population, depending on series.\textsuperscript{1} While some
variations may be associated with increased risk of ischemic events or
sudden death, others may be benign findings which do not pose additional
risk nor warrant treatment. Even less described is the usage of donor
hearts with anomalous coronary anatomy for transplantation. In this
article, we present a case of successful utilization of a donor graft
with a single coronary artery for transplantation.

\emph{Case Description}

This study was approved by our institutional review board
(MOD18120143-003, approved 3/9/2020), and written consent was obtained.

A 60-year-old male with history of nonischemic cardiomyopathy with left
ventricular ejection fraction of 20\% was admitted to the hospital with
recurrent ventricular tachycardia. He had undergone three unsuccessful
ablation procedures and had also failed multiple outpatient
anti-arrhythmic pharmacotherapies. While inpatient, he was maintained on
a continuous intravenous infusion of lidocaine. Initially, he was listed
as Status 3E, and remained inpatient awaiting a heart offer for over
four months. Eventually, he was upgraded to Status 2E due to increased
burden of ventricular tachycardia. On post-upgrade day 16, he received a
donor offer.

The donor was a 40-year-old male who underwent brain death pronouncement
after sustaining blunt head trauma. On echocardiography, the heart had
good biventricular function. Due to the donor's age, left coronary
catheterization was performed which revealed an anomalous origin of the
left coronary artery (LCA). The LCA and right coronary artery arose from
a single ostium within the right sinus of Valsalva (Figure A). Chest
computed tomography demonstrated a retro-aortic course of the LCA
(Figure B). A discussion was held among the heart failure cardiology and
cardiac surgery team. Because the LCA did not appear to have an
inter-arterial or other malignant course, the decision was made to
pursue transplantation. A heart team was sent to the donor facility, and
the heart was accepted and later transplanted (Video). Transplantation
was performed using our usual implantation technique without
modification, beginning with the left atrial cuff anastomosis followed
by the aortic anastomosis.

The patient did well post-transplant. His hospital course was prolonged
primarily due to pretransplant physical conditioning, having been
hospitalized for four months prior to transplant. On posttransplant day
36, he was discharged to a rehabilitation facility, and was discharged
home 24 days later.

\emph{Discussion}

Anomalous origins of coronary arteries are infrequent phenomena within
the general population, and seldomly encountered at time of heart
transplantation. Because left heart catherization is not routinely
performed as part of the standard evaluation of donor grafts, unless the
donor is male and older than 45 (or \textgreater{}50 years for female
donors) or other concerns for possible coronary artery disease exist,
these findings are typically unknown prior to procurement. Several
reports\textsuperscript{2--4} have documented the use of donor heart
grafts with anomalous coronary anatomy. However, in most cases, these
findings are often not recognized until the time of in-person donor
evaluation, or even after donor cardioectomy. In this case, left heart
catheterization was performed prior to evaluation by the surgical team,
and thus, the diagnosis of single coronary artery was known beforehand.

Various variations of aberrant coronary anatomy exist, all with separate
risk profiles. The most lethal variant described is the LCA originating
from the right coronary sinus with an inter-arterial course, which
carries the highest risk of sudden or exercise-induced death,
particularly in younger patients.\textsuperscript{5} As in our case, a
retro-aortic course of an aberrant coronary is generally thought to have
no hemodynamic consequence.\textsuperscript{6} Given these facts, we
felt this anatomy to be a benign variation and a suitable graft for this
recipient -- a gentleman of increased age and with prolonged hospital
course. Given the fact the patient remained hospital-dependent for more
than 4 months awaiting a heart offer, the benefits of transplantation of
this donor graft appeared to outweigh the risks of continued
hospitalization and waiting. Given the coronary anatomy, implantation of
the cardiac graft did not require modification from usual practice,
unlike that of Vasseur and colleagues, who applied a slight modification
using a shorter pulmonary artery trunk and longer aortic trunk to create
a wide aorto-pulmonary window for implantation of a graft with an
inter-arterial LCA.\textsuperscript{3}

Though a relatively uncomplicated immediate posttransplant course, it is
unclear how this graft may perform in the long-term. A previous
retrospective analysis\textsuperscript{1} has suggested that perhaps
anomalous coronary artery patters may demonstrate a higher prevalence of
significant atherosclerosis, however, little is known about the
development of chronic allograft vasculopathy within a transplanted
graft.

\emph{References}

1. Sidhu NS, Wander GS, Monga A, Kaur A. Incidence, Characteristics and
Atherosclerotic Involvement of Coronary Artery Anomalies in Adult
Population Undergoing Catheter Coronary Angiography. \emph{Cardiol Res}
. 2019;10(6):358. doi:10.14740/CR941

2. Oliveros E, Pauwaa S, Andrade A, et al. Malignant course of an
anomalous coronary artery in a transplanted heart. \emph{J Am Coll
Cardiol} . 2019;73(9):2724. doi:10.1016/s0735-1097(19)33330-3

3. Vasseur BG, Anderson MB, Freudenberger RS. Anomalous coronary artery
in a transplanted heart: A technical modification. In: \emph{Journal of
Heart and Lung Transplantation} . Vol 23. J Heart Lung Transplant;
2004:1008-1009. doi:10.1016/S1053-2498(03)00234-1

4. Patlolla SH, Vallabhajosyula S, Bell MR. Incidental Anomalous Left
Coronary Artery in a Transplanted Heart. \emph{Case Reports Cardiol} .
2019;2019:1-3. doi:10.1155/2019/2715896

5. Taylor AJ, Rogan KM, Virmani R. Sudden cardiac death associated with
isolated congenital coronary artery anomalies. \emph{J Am Coll Cardiol}
. 1992;20(3):640-647. doi:10.1016/0735-1097(92)90019-J

6. Kastellanos S, Aznaouridis K, Vlachopoulos C, Tsiamis E, Oikonomou E,
Tousoulis D. Overview of coronary artery variants, aberrations and
anomalies. \emph{World J Cardiol} . 2018;10(10):127.
doi:10.4330/WJC.V10.I10.127

\textbf{Figure.} Evaluation of donor cardiac graft included A) left
heart angiogram demonstrating both left and right coronary arteries
arising from single ostium within the right sinus of Valsalva and B)
chest computed tomography revealing retro-aortic course of the left
coronary artery. LAD = left anterior descending, LCA = left coronary
artery, RCA = right coronary artery\selectlanguage{english}
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