Aortic Valve Replacement Challenge in a Patient With a High Take-off Right Coronary Artery

High take-off right coronary artery (RCA) is a rare coronary variation with an incidence rate of 0.019% to 0.17% that can make disturbances during cardiac surgery. This abnormality may be silent clinically and diagnosed during the surgical repair of coexisting anomalies such as aortic valve abnormalities and ventricular or atrial septal defects or at autopsy evaluation of an athlete with sudden cardiac death. We herein describe a middle-aged man who suffered from exertional dyspnea. The patient had no history of concurrent diseases. Echocardiography revealed a left ventricular ejection fraction of 50% and severe stenosis in the aortic valve (gradient =70 mm Hg). He was scheduled for aortic valve replacement. However, during preoperative angiographic assessments, attempts to cannulate the right coronary ostium were unsuccessful. During surgery, a high take-off RCA was incidentally found with a long intramural course. The artery was saved and internally fenestrated into the right sinus after a modified aortotomy along with aortic valve replacement. (Iranian Heart Journal 2021; 22(4): 145-147)