Left main coronary artery stenosis after aortic valve replacement: genetic disposition for accelerated arteriosclerosis after injury of the intact human coronary artery?

Transesophageal echocardiography: a tool for intraoperative assessment of coronary blood flow

Transesophageal echocardiography (TEE) has become an indispensable part of cardiac surgery, but its potential for assessing coronary anatomy and blood flow remains underutilised. This case report presents a case of acute iatrogenic left main coronary artery obstruction following re-operative aortic valve replacement that was promptly diagnosed by intraoperative TEE and managed successfully by Bentall operation. We also emphasise the technique of TEE for coronary evaluation, its caveats and its clinical application during cardiac surgery.

Myocardial ischaemia caused by bilateral coronary ostial stenosis from pseudointimal membranes in a full root freestyle valve: a case report

Background

Coronary artery ostial stenosis is a rare but well-known complication to aortic root replacement. The occurrence of this complication in patients with the Medtronic Freestyle bioprosthesis is poorly described. We report a case of late bilateral coronary ostial stenosis due to pseudointimal membranes within a Medtronic Freestyle bioprosthesis, resulting in acute coronary syndrome.

Case summary

In 2013, a 43-year-old male patient received a Medtronic Freestyle bioprosthesis as a full aortic root implantation due to endocarditis with root abscess. Preoperative coronary angiography was normal. The patient, who had no previous symptoms of coronary ischaemia, presented with severe chest pain and acute coronary syndrome in 2017. Coronary angiography and electrocardiogram-gated contrast-enhanced cardiac computed tomography showed bilateral coronary ostial stenosis. The patient was successfully treated with coronary artery bypass grafting. Intraoperative inspection revealed pseudointimal membranes covering the coronary ostia. Histology showed fibro-intimal thickening with areas of inflamed granulation tissue.

Discussion

Bilateral coronary ostial stenosis is a severe, potentially life-threatening condition, and a possible complication to implantation of the Medtronic Freestyle bioprosthesis as a full root. The phenomenon may occur late and should be distinguished from arteriosclerotic coronary artery disease.

Intraoperative Transesophageal Echocardiography for Coronary Artery Assessment

Background: In surgical aortic valve replacement (SAVR), coronary arteries are routinely assessed by transesophageal echocardiography (TEE) to prevent undesirable complications. This study evaluated the capabilities and pitfalls of TEE assessment. Methods and Results: Of 147 consecutive SAVR patients undergoing aortic stenosis, the TEE records for 130 patients, in which the procedures were conducted by a single examiner, were analyzed retrospectively regarding data acquisition and the accuracy of detecting an anomalous origin, high or low takeoff, ostial diameter, and short left main truncus (LMT). The left and right coronary arteries could be visualized in every patient. A left coronary ostium >5 mm was found in 33 patients (25.4%). TEE revealed an anomalous origin in 2 patients (1.5%) that had not been diagnosed, but missed it in another patient. High takeoff was noted in 11 patients (8.3%), often associated with aortic disease necessitating aortic repair. In one such patient, occlusion of the right coronary artery was detected, necessitating coronary revascularization. Short LMT was found in 15 patients (11.8%) but misdiagnosed due to artifact in 1. During selective cardioplegia, malperfusion of the left anterior descending artery due to deep cannula placement was detected. Conclusions: TEE provides fairly accurate assessment in SAVR, including detection of undiagnosed pathologies or pitfalls related to coronary arteries, although misdiagnosis due to artifacts should be kept in mind.

Biostial iatrogenic coronary artery stenosis: a rare complication of aortic valve surgery successfully treated with percutaneous coronary stenting

A 66-year-old woman presented 4 months after conventional surgical aortic valve replacement with an acute coronary syndrome resulting from rare iatrogenic biostial left main and right coronary artery stenoses, which were successfully treated with percutaneous coronary stenting, optimized by intracoronary imaging.

Coronary ostial stenosis detected by transesophageal echocardiography after aortic valve replacement: a case report

Background

Coronary ostial stenosis is a life-threatening complication of aortic valve replacement (AVR). Clinical symptoms usually appear within the first 6 months after AVR (Funada and Mizuno et al., Circ J 70:1312–7, 2006), and perioperative onset is very rare.

Case presentation

An 80-year-old woman with severe aortic stenosis was scheduled to undergo AVR. AVR using cardiopulmonary bypass (CPB) was successfully carried out. However, 5 min following AVR, signs of left heart failure appeared, and transesophageal echocardiography (TEE) revealed severe hypokinetic left ventricular wall motion. Left coronary ostial stenosis was diagnosed by TEE, and CPB was immediately resumed and coronary artery bypass grafting (CABG) to the left anterior descending branch was performed.

Conclusions

When circulatory failure presents in the acute phase following AVR, onset of coronary ostial stenosis should be considered.

Re-operation for Tetralogy of Fallot with Single Right Coronary Artery

A 7-year-old girl with tetralogy of Fallot in association with a single right coronary artery, was successfully re-operated on for right ventricular outflow tract obstruction. To identify the course of the abnormal coronary arteries during the re-operation, a probe was directly inserted into the coronary arteries after aortotomy. Ventriculotomy was successfully performed under the guide of the probe, without damaging the coronary arteries. Double outflow technique was applied for the relief of the right ventricular outflow tract obstruction.

An unusual case of cardiogenic shock late following surgical aortic valve replacement

The present case describes a rare but potentially life-threatening complication following surgical aortic valve replacement (AVR): iatrogenic coronary ostial stenosis (ICOS). The incidence of ICOS is estimated to be between 0.3% and 5% of all AVR and it generally occurs within 6 months after the procedure. In most cases, either the left main stem or the ostium of the right coronary artery (RCA) is affected, although stenosis of the ostium of the left anterior descending artery can also occur. However, to the best of our knowledge, the simultaneous involvement of both coronary ostia, presenting with rapid onset cardiogenic shock requiring inotropic support and intra-aortic balloon pump placement, has never been reported. <Learning objective: Iatrogenic coronary ostial stenosis (ICOS) is a rare but possible complication that can occur after aortic valve replacement. When ICOS is suspected, especially in unstable patients, a prompt diagnosis and early revascularization therapy is crucial. In this clinical setting, coronary percutaneous coronary intervention appears to be the best revascularization option.>.

Iatrogenic left main coronary artery stenosis following aortic and mitral valve replacement

Iatrogenic coronary artery disease following prosthetic valve implantation is a rare complication. This may result from mechanical injury in the intraoperative period. The use of balloon tip perfusion catheter presumably provides the initial insult with local vessel wall hypoxia. Once the diagnosis of coronary ostial stenosis is established, the procedure of choice is coronary artery bypass surgery. We report a case of a young lady who underwent aortic and mitral valves replacement for infective endocarditis. She was then diagnosed with ostial left main stem coronary stenosis after presenting with atypical symptoms. The patient eventually underwent coronary artery bypass surgery.

Acute coronary syndrome as a result of left main coronary artery stenosis after aortic valve replacement. A report of three cases

Acute coronary syndrome (ACS) as a result of iatrogenic coronary ostial stenosis (ICOS) is a rare but potentially life-threatening complication of aortic valve replacement (AVR). We present three cases of patients with ACS shortly after AVR, in whom ICOS were revealed. They refused an operation and thus they were treated with percutaneous coronary intervention. The potential pathomechanisms of ICOS and treatment options are discussed.

Is percutaneous transluminal coronary angioplasty the treatment of choice for iatrogenic stenosis of the left main coronary artery following aortic valve replacement?

Iatrogenic coronary ostial stenosis after aortic valve replacement (AVR) is a rare but life-threatening complication. This condition has been treated with urgent coronary bypass surgery, but such surgery is associated with high morbidity and mortality. The clinical symptoms are usually severe and may appear from 1 to 6 months postoperatively. Pains in the chest that are typical for coronary artery disease but occur in patients after the AVR operation suggest a significant threat. We report a case of left main coronary artery ostial stenosis in a patient who had normal preoperative coronary angiography results. The patient was successfully treated with implantation of a drug-eluting stent.

Unstable angina early after aortic valve replacement surgery in a female patient with normal coronary arteries preoperatively--a case report

BACKGROUND

Angina pectoris early after aortic valve replacement surgery in patients with previously normal coronary arteries may be life threatening and has to be assessed immediately.

CASE REPORT

12 weeks after aortic valve replacement surgery, a 60-year-old female patient was referred for evaluation of recent onset of severe chest pain on mild exertion and at rest. Coronary angiography showed severe stenosis involving the left coronary ostium and the left main stem. The patient was urgently referred for bypass surgery and had an uneventful postoperative recovery.

CONCLUSION

A high degree of suspicion is needed for early recognition and aggressive management of this rare but serious complication.

Three Cases of Iatrogenic Coronary Ostial Stenosis After Aortic Valve Replacement

BACKGROUND

Iatrogenic coronary ostial stenosis (ICOS) is a rare but potentially life-threatening complication of aortic valve replacement (AVR). This complication is usually diagnosed by angiography and treated with aortocoronary bypass surgery.

CASE REPORTS

In the present 3 cases pre-operative coronary angiography confirmed normal coronary arteries and they underwent uncomplicated AVR. Coronary lesions were clinically manifest within 4 months after surgery, and repeat coronary angiography demonstrated bilateral ostial stenosis in 1 patient and left main trunk stenosis in the other 2. Two cases were detected by multidetector computed tomography (MDCT) before angiography. MDCT and Virtual Histology suggested fibrous tissue formation in the lesions. All 3 patients were successfully underwent percutaneous coronary intervention (PCI) and stenting. The post-procedure clinical course has been uneventful, except for elective stenting of a recurrent lesion in 1 asymptomatic patient.

CONCLUSIONS

The incidence of ICOS after AVR is low. Noninvasive MDCT is useful for early diagnosis and PCI is a possible alternative treatment. ICOS may be caused by fibrous tissue formation, and therefore be distinct from conventional atherosclerosis.

Coronary Ostial Stenosis After Aortic Valve Replacement, Revisited

Coronary artery occlusive disease that develops after an uncomplicated aortic valve replacement is well recognized. We present a case that required two further coronary operations and two salvage angioplasty procedures for a continuing fibrotic process in the ascending aorta. The literature and pathology are reviewed.

Coronary ostial enlargement to prevent stenosis after prosthetic aortic valve replacement

Iatrogenic left and/or right coronary artery ostial stenosis after aortic valve replacement is a rare but life-threatening complication. Although usually related to trauma to the ostium/a during cannulation for administration of cardioplegia, it may be rarely due to direct obstruction by the prosthetic annular ring or stent. We report herein an alternative technique to manage this complication when due to the latter event, successfully utilized at our institution over the last eleven years.

Underexpression of the apolipoprotein E2 and E4 alleles in the Greek Cypriot population of Cyprus

Apolipoprotein E (APOE) plays an important role in the multifactorial etiology of both cardiovascular disease and Alzheimer's disease. Polymerase chain reaction (PCR) was used to investigate the APOE gene polymorphism in 335 unrelated Greek Cypriots living on the island of Cyprus. For the most common APOE genotypes, the Greek Cypriots followed the general Caucasian European pattern of having higher genotypic frequencies of E3/3, followed by E3/4, and then E2/3. Among the European populations compared, Greek Cypriots exhibited the lowest relative frequency of the E3/4 genotype (12.83%). Also, the relative frequencies of the E2 and E4 alleles in Greek Cypriots were among the lowest around the world (5.4% and 7.0%, respectively). This was also demonstrated by using the complete and the average clustering methods of analysis where the APOE allele relative frequencies in Greek Cypriots were compared to 46 other populations. The Greek Cypriot population in these analyses clustered with populations mainly from south Europe and Japan which have low E2 and E4 allele frequencies. The Greek Cypriot population will be studied further for elucidating the effect(s) and the role of APOE in cardiovascular disease and the APOE4 allele as a possible metabolic factor affecting the rate of expression of both Alzheimer's disease and vascular dementia.