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A patient with advanced rheumatic heart valve disease underwent aortic and mitral valve replacement with tricuspid ring annuloplasty. There was an anomalous left circumflex coronary artery (LCCA) arising from the right coronary artery (RCA) running along the anterior surface of an enlarged right ventricle (RV). During the immediate postoperative course, signs of inferior and lateral myocardial ischemia developed. An emergent coronary angiography revealed LCCA entrapment. An additional suture placed in the RV outflow tract used to optimize exposition of the aortic root during the aortotomy was determined to be the origin of the coronary entrapment. No similar case of LCCA occlusion has previously been reported. This is a description of successful management of this complication.

A 45-year-old woman presented with weakness and progressive dyspnea. She had a previous history of severe renal insufficiency treated with hemodialysis and a permanent right jugular central venous catheter as dialysis access. On the physical examination, there were no relevant findings. Electrocardiography showed sinus rhythm. Surprisingly, on chest radiography, a cardiomegaly was detected. Transthoracic echocardiography was achieved and revealed a giant mass located on the right atrium (RA), protruding through the tricuspid valve causing tricuspid regurgitation (Fig. A). Due to the presence of a central venous catheter, the mass was initially misdiagnosed as a thrombus. However, a magnetic resonance (MR) angiography was done and ruled out this possibility (Fig. B). The patient underwent cardiac surgery. Transesophageal echocardiography intraoperatively showed the mass (Fig. C, D). Median sternotomy was performed and standard cardiopulmonary bypass established. A giant 8x7 cm yellowish-red mass arising from the RA and attached to the inferior vena cava was found. It had a smooth surface with nodules and hemorrhagic areas (Fig. E). The tumor was excised and sent to the Pathology Department and was considered to be a cardiac myxoma. Myxomas are the most common type of benign cardiac tumors. They are usually located on the left atrium, and only exceptional cases grow on the right side of the heart. Diagnosis is difficult because the majority of cases remain asymptomatic. When symptomatic, the clinical presentation is related with embolization or atrioventricular valve dysfunction. Differential diagnosis must be done with malignant tumors or thrombus (especially in the presence of a central venous catheter). Echocardiography and MR play an important role in the diagnosis. Surgical removal is the elective treatment. Recurrences occur when excision of the tumor is incomplete. 113