Anomalous Left Circumflex Artery in Valve Interventions: Surgical and Transcatheter Challenges

BACKGROUND: Anomalous origin of the left circumflex coronary artery (AOLCX) with a retroaortic course is at risk of compression during valve interventions. Although AOLCX is typically benign, iatrogenic injury can cause catastrophic ischemia. As transcatheter aortic valve replacement (TAVR) expands to lower-risk populations, understanding mechanisms of injury in both surgical and transcatheter settings is becoming crucial. METHODS: A narrative review was performed focusing on anatomic risks, injury mechanisms, and management of AOLCX. Forty-five relevant publications were synthesized to integrate technical and anatomic evidence. RESULTS: Left circumflex artery compromise is determined by the vessel's proximity to the aortic and mitral annuli. In surgery, deep sutures and prosthetic rings are the primary causes. In TAVR, mechanisms involve retroaortic compression and ostial occlusion, necessitating preprocedural assessment of coronary height, sinus dimensions, calcification, and annular proximity. Preventive strategies include surgical mobilization, prophylactic bypass, and guidewire protection. Bailout strategies include bypass and emergency stenting. For aortic stenosis, procedure selection between surgery and TAVR should be individualized on the basis of age, calcification, and anatomic metrics. Late complications such as delayed coronary obstruction necessitate longitudinal surveillance. CONCLUSIONS: Preprocedural computed tomographic angiography is essential to quantify anatomic risk. A heart team approach is required to select the optimal intervention and implement mechanism-specific protection. Long-term clinical and imaging surveillance is warranted to prevent both acute and delayed left circumflex artery compromise.