ARCAPA Unveiled During Preoperative Assessment for Mitral Valve Repair: Clinical Implications of an Incidental Finding.

BACKGROUND: Anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA) in association with primary mitral regurgitation is an exceedingly uncommon congenital anomaly. CASE SUMMARY: A 56-year-old man with progressive dyspnea for 12 years, apparently because of degenerative mitral regurgitation, was incidentally diagnosed with ARCAPA on coronary angiography during preoperative evaluation for mitral valve repair. Coronary computed tomography angiography confirmed ARCAPA, detailing the aberrant anatomy. The patient underwent successful complex mitral valve repair, closure of the coronary-pulmonary artery connection, and reimplantation of the right coronary artery into the ascending aorta, with modified cardioplegia. Postoperative imaging demonstrated effective repair and restoration of normal coronary perfusion. DISCUSSION: ARCAPA is diagnosed by dilated right coronary artery, retrograde flow, and extensive collaterals on imaging. Correction of coronary steal and restoration of 2-vessel anatomy can be achieved through surgical repair or an endovascular approach. TAKE-HOME MESSAGES: ARCAPA should be considered in the differential diagnosis of adult onset exertional dyspnea. A missed preoperative diagnosis may lead to catastrophic ischemia following cardioplegia delivery.