Second and larger than normal aortic annulus triple aortic annulus in a patient with ascending aortic aneurysm and bicuspid aorta

Ascending aortic aneurysm is the most common type of thoracic aortic aneurysm, and it may be accompanied with aortic regurgitation, coarctation, bicuspid aortic valve, or coronary anomaly. Because of structural variations, anatomic locations of aortic structures like coronary arteries may dislocate or some additional morphological changes may be seen. In this report, we present the case of a 69-year-old male patient admitted to a cardiology clinic with the diagnosis of ascending aortic aneurysm. Patient presented to a cardiology outpatient clinic where he was evaluated with transthoracic echocardiography, and the ascending aorta was measured to be 65 mm in parasternal long-axis view. He had moderate aortic regurgitation, and ejection fraction (EF) was found to be 60%. He was referred to a tertiary center for coronary angiography and aortic surgery. Coronary angiography was performed by puncturing the right femoral artery. Due to aneurysmatic dilatation and anatomic challenges, selective coronary imaging could not have done very successfully. In every effort to reach the left and right coronary ostia, different types of diagnostic and guiding catheters (judkins, extra backup, amplatz left etc.) were restrained by an anatomic structure that is located in the distal portion of the aortic root. Aortography was performed that showed a linear line restraining the filling up of the coronary ostia (Fig. 1, Video 1). Challenging imaging of coronaries unselectively could have been performed, and the patient was transferred to a cardiovascular surgery clinic for ascending aortic surgery