Anomalous origins of coronary arteries are infrequent phenomena within the general population, and seldomly encountered at time of heart transplantation. Because left heart catheterization is not routinely performed as part of the standard evaluation of donor grafts, unless the donor is male and older than 45 (or > 50 years for female donors) or other concerns for possible coronary artery disease exist, these findings are typically unknown prior to procurement. Several reports [2,3,4] 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 [5]. As in our case, a retro-aortic course of an aberrant coronary is generally thought to have no hemodynamic consequence [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 a prolonged pre-transplant hospitalization. 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. When evaluating these grafts, we advocate that great care be taken to ensure there is no evidence of flow limitation or restriction through the anomalous coronary artery. Any suspicion of ischemia through donor history or cause of death should be of concern. When performing angiography of these vessels, intravascular ultrasound may be a useful tool to rule out impingement, restriction, or any other flow-limiting lesions of these anomalous vessels if concern exists. Given the coronary anatomy in this case, 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 [3].

Though a relatively uncomplicated immediate posttransplant course, it is unclear how this graft may perform in the long-term. A previous retrospective analysis [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 .