A case of anomalous left coronary artery obstruction caused by lotus valve implantation

Trans‐catheter aortic valve implantation (TAVI) in patients with high surgical risk is an alternative therapeutic option for severe aortic stenosis. Although second generation TAVI devices are available now, this therapy still cannot overcome all serious complications. Among them, coronary obstruction is a life threatening complication, however, there is no report concerning the complication in patients with anomalous coronary arteries. Here we present a case with coronary obstruction of an anomalous left main coronary that occurred after implantation of the mechanical expanding Lotus valve (Boston Scientific Inc.). © 2016 Wiley Periodicals, Inc.     

Results of coronary bypass and valve operations for mitral valve regurgitation

Combined coronary bypass grafting and valve procedures for mitral valve regurgitation result in poor outcomes, but the impact of the etiology of valve regurgitation on operative and long-term outcomes is not well defined. A retrospective analysis of 468 patients who had combined coronary bypass grafting and valve operations for mitral regurgitation showed that 78% had valve repairs and 22% had replacements for ischemic (45%) or degenerative (55%) disease. Predictors of operative mortality were ischemic mitral regurgitation, failure to use the internal mammary artery for grafting, severe coronary disease, acute myocardial infarction, low ejection fraction, advanced heart failure, emergency operation, and mitral valve replacement. The 5-year survival rates for propensity-matched patients with ischemic or degenerative disease were similar (66%). Low ejection fraction (< 35%), advanced age (> 67 years), valve replacement surgery, residual mitral regurgitation, and severe coronary artery disease were predictors of poor long-term outcome. Although the operative outcomes of ischemic mitral regurgitation were poor compared to those of degenerative disease, the long-term survival was similar in both groups of propensity-matched patients. Left ventricular remodeling, an optimal valve procedure without residual mitral regurgitation, and left ventricular function are more important determinants of long-term outcome than the etiology of valve regurgitation.     

In vitro study of coronary flow occlusion in transcatheter aortic valve implantation

Background

Transcatheter aortic valve implantation (TAVI) has been developed recently for patients with high morbidities and who are believed to be not tolerate standard surgical aortic valve replacement. Nevertheless, the TAVI is associated with complications such as potential obstruction of coronary ostia, mitral valve insufficiency, and stent migration although it seems promising. Impairment of the coronary blood flow after TAVI is catastrophic and it was believed to be associated with the close position of the coronary orifice and the aortic leaflets and valve stent. However, few data was available as to the anatomic relationship between valve stent and aortic root anatomic structures including the coronary arterial ostia, aortic leaflets.

Methods

The aortic roots were observed in 40 hearts specimens. The width of aortic leaflet, height of aortic sinus annulus to the sinutubular junction (STJ), distance between aortic sinus annulus to its corresponding coronary ostia, and coronary arterial ostia to its corresponding STJ level were measured. Moreover, the relationships of valve stent, aortic leaflets and coronary ostia before/post stent implantation and after the open of aorta were evaluated respectively.

Results

Approximate three quarters of the coronary ostia were located below the STJ level. The mean distances from left, right and posterior aortic sinus annulus to the related STJ level was comparable, which was 18.5±2.7, 18.9±2.6, 18.7±2.6 mm, respectively. Meanwhile, the height of left and right aortic sinus annulus to its corresponding coronary ostia was 16.6±2.8 and 17.2±3.1 mm for left and right side respectively.

Conclusions

Most of the coronary ostia were located below the STJ level and could be covered by the leaflets. This highlights the need of modified stents to prevent occlusion of coronary flow after TAVI.     

Combined percutaneous coronary intervention and valve surgery

PURPOSE OF REVIEW: This article reviews unique advantages emerging in valvular heart disease as the technology of invasive cardiology and cardiac surgery begin to merge. RECENT FINDINGS: Minimally invasive valve surgery is increasing in popularity and has helped to reduce morbidity. In addition, preoperative or intraoperative treatment of coronary artery disease by a percutaneous approach has simplified operations and allowed more liberal use of non-traditional incisions. SUMMARY: Percutaneous intervention with drug-eluting stents has provided early evidence for decreased restenosis and improved long-term patency rates. At the same time, cardiac surgery has moved toward less invasive approaches performed in new imaging arenas known as 'hybrid' operating rooms. Combining these technological advances is providing unique solutions to valvular heart disease also requiring revascularization, and will likely become the next horizon for strategies in cardiovascular medicine.     

Left main coronary artery bifurcation angioplasty and stenting after aortic valve replacement: a case report

A 43-year-old young lady had closed mitral valvotomy (CMV) in 1994 and aortic valve replacement (AVR) in June 2007. Shortly thereafter, she presented with unstable angina in October 2007 with on-going pain and haemodynamic instability. Coronary angiogram showed tight left main bifurcation stenosis in a left dominant system. Having had open heart surgery (AVR) recently, and being on oral anticoagulation, with on-going ischaemia and unstable haemodynamics, percutaneous coronary intervention (PCI) was considered the most suitable option. She underwent successful PCI with two drug-eluting stents (T-stenting) to left main bifurcation through transradial approach and intra-aortic balloon support. Clinically she remained symptom free and coronary angiogram after 5 months and 15 months of follow-up showed patent stents. This case demonstrates the acute effectiveness of PCI for the treatment of critical left main disease following open heart surgery in patients who are not appropriate surgical candidates.     

Percutaneous coronary intervention for extrinsic coronary compression after pulmonary valve replacement.

Coronary artery compression is a rare and potentially fatal complication after pulmonary valve replacement. This report describes myocardial infarction from extrinsic left main coronary artery compression after pulmonary valve replacement in a 10-y-old boy. He was successfully treated with percutaneous coronary intervention.     

Mitral valve prolapse due to coronary artery disease

Controversy exists concerning the etiologic role of coronary artery disease in the prolapsing mitral valve leaflet syndrome. A 35 year old man with progressive coronary artery disease is described. Auscultation before and after his first myocardial infarction revealed only a fourth heart sound; subsequent left ventricular cineangiography demonstrated normal anatomy and function of the mitral valve, despite extensive wall motion abnormalities. Six months later he experienced another myocardial infarction after which the typical mid-systolic click, late systolic murmur of mitral valve prolapse developed. A second left ventricular cineanglogram at this time revealed mid-systolic mitral valve prolapse and mitral regurgitation. This patient's course indicates that myocardial damage from coronary artery disease can cause mitral valve prolapse in patients without preexisting redundant mitral valve tissue.     

Aortic valve lymphoma presenting as acute coronary syndrome

Primary cardiac lymphoma is a very rare tumor which commonly affects the right atrium, although any chamber may be affected. Over the past few decades, the incidence of the lesion has increased, due mainly to growing numbers of immunocompromised patients, either HIV-related or iatrogenic. Because of this rapid evolution, the situation represents an oncologic emergency, and therefore early diagnosis and treatment are crucial. Although MRI is the most sensitive modality, open biopsy remains the 'gold standard' for reaching the diagnosis. However, the overall prognosis is poor. Herein is presented a case of a large B-cell non-Hodgkin lymphoma involving only the aortic valve.     

Mitral valve prolapse in coronary artery disease.

Mitral valve motion, left ventricular segmental contraction and severity of arterial stenosis were analyzed in 92 patients with coronary artery disease and 28 patients with "atypical chest pain" and normal coronary arterio-rams. Mitral valve motion was evaluated for the presence or absence of leaflet prolapse. Segmental contraction was evaluated by calculating the percent shortening of six chords of the left ventricle measured from right anterior oblique ventriculograms. The severity of disease in each coronary vessel (left anterior descending, left circumflex and right coronary) was graded on a scale of 1 (0 to 30 percent stenosis) to 5 (complete occlusion). Mitral valve prolapse was not suspected clinically but observed angiographically in 15 of 92 patients with coronary artery disease and in 5 of 28 patients with normal coronary arteriograms. In nine patients with coronary artery disease, the prolapse was restricted to the posterior leaflet, in five it was in both the anterior and the posterior leaflets and in one patient in the anterior leaflet only. Mitral regurgitation was noted in seven patients with coronary artery disease; it was mild in six and moderate in one. Among the patients with coronary artery disease, 12 of the 15 (80 percent) with mitral valve prolapse had left ventricular asynergy compared with 63 of the 77 (82 percent) without valve prolapse. The mean scores for severity of disease in the left anterior descending, circumflex and right coronary arteries were, respectively, 4.2, 2.5 and 3.2 in the patients with valve prolapse and 4.2, 2.2 and 3.5 in those without prolapse. In summary, there was no significant correlation between mitral valve prolapse and distribution of coronary arterial obstructions or abnormal patterns of left ventricular segmental contraction. There was a high frequency of mitral valve prolapse in patients with severe coronary artery disease and in those with normal coronary arteriograms and atypical chest pain.     

Anomalous right coronary ostium complicating aortic valve replacement

Unanticipated association of coronary artery anomaly with acquired heart disease may create a difficult problem. A rare association of anomalous right coronary artery with aortic stenosis undergoing valve replacement with a Toronto stentless porcine valve presented difficulties.     

Staged initial percutaneous coronary intervention followed by valve surgery ("hybrid approach") for patients with complex coronary and valve disease

OBJECTIVES: The goal of this study was to determine if a "hybrid" approach to the treatment of complex combined coronary and valve disease is superior to the results predicted by a Society of Thoracic Surgeons' (STS) algorithm with conventional coronary artery bypass graft (CABG)/valve surgery in high-risk patients. BACKGROUND: With advancements in percutaneous coronary interventions (PCIs), some patients requiring coronary revascularization and valve surgery may benefit from a hybrid approach involving initial planned PCI followed by valve surgery, rather than conventional CABG/valve surgery. METHODS: We retrospectively analyzed 26 consecutive patients with coronary artery and valve disease who underwent planned initial PCI followed by valve surgery during the same hospital stay between September 1997 and August 2003. We calculated the predicted mortality at the time of PCI and compared it with the observed mortality. RESULTS: There were 12 male and 14 female patients with a median age of 72 years (range 53 to 91 years). Balloon angioplasty was performed in all patients, followed by stenting in 22 (85%) patients. Within a median of 5 days (range 0 to 14 days), 15 patients (58%) underwent primary and 11 patients (42%) underwent re-operative valve surgery. Operative mortality was 1 of 26 patients (3.8%), dramatically lower than the STS-predicted mortality of 22%. Median blood loss was 900 ml, and 22 patients (85%) required blood transfusions. Survival at 1, 3, and 5 years was 78%, 56%, and 44%, respectively. CONCLUSIONS: Hybrid initial PCI followed by staged valve surgery represents an excellent alternative to conventional CABG/valve surgery in some high-risk patients, particularly those who present in shock after myocardial infarction. Lower mortality rates come at the cost of more bleeding and transfusion requirements.     

Assessment of coronary artery disease using coronary computed tomography angiography in patients with aortic valve stenosis referred for surgical aortic valve replacement

Background

In patients referred for aortic valve replacement (AVR) a pre-surgical assessment of coronary artery disease is mandatory to determine the possible need for additional coronary artery bypass grafting. The diagnostic accuracy of coronary computed tomography angiography (coronary CTA) was evaluated in patients with aortic valve stenosis referred for surgical AVR.

Methods

Between March 2008 and March 2010 a total of 181 consecutive patients were included. All patients underwent pre-surgical coronary CTA (64- or 320-detector CT scanner) and invasive coronary angiography (ICA). The analyses were performed blinded to each other.

Results

The mean ± SD age of the included patients was 71 ± 9 years and 59% were male. The prevalence of significant coronary artery stenosis > 70% by ICA was 36%. Average heart rate during coronary CTA was 65 ± 16 bpm. In a patient based analysis 94% of the patients (171/181) were considered fully evaluable. Coronary CTA had a sensitivity of 68%, a specificity of 91%, a positive predictive value of 81%, and a negative predictive value of 83%. Advanced age, obstructive lung disease, NYHA function class III/IV, and high Agatston score were found to be significantly associated with disagreement between ICA and coronary CTA in univariate analysis.

Conclusion

In patients with aortic valve stenosis referred for surgical AVR the diagnostic accuracy of coronary CTA to identify significant coronary artery disease is moderate. Coronary CTA may be used successfully in a subset of patients with low age, no chronic obstructive lung disease, NYHA function class < III and low coronary Agatston score.