Transaortic patch angioplasty for left coronary ostial stenosis in a patient with Takayasu's aortitis.

A 35-year-old woman who had left coronary ostial stenosis and aortic valve regurgitation due to Takayasu's aortitis underwent transaortic patch enlargement of the stenosed left coronary ostium in combination with aortic valve replacement. This technique may be suitable and recommendable as an alternative to aortocoronary bypass grafting or endarterectomy for coronary ostial stenosis in Takayasu's aortitis.     

A case report of aortitis syndrome with massive aortic regurgitation (AR), and ostial stenosis of the right coronary artery

A 55-year-old female with massive aortic regurgitation and ostial stenosis of the right coronary artery due to aortitis syndrome was reported. The patient was admitted to the hospital with anterior chest pain and dyspnea on exertion. Retrograde aortogram showed massive aortic regurgitation and selective coronary angiogram revealed ostial stenosis of the right coronary artery. She was treated with aorto-coronary bypass (A-C bypass) and aortic valve replacement (AVR) with St. Jude Medical prosthetic valve. At operation, ostial stenosis of the right coronary artery due to aortitis syndrome was confirmed. Aortic valve replacement with a prosthetic valve and saphenous vein grafting to the distal right coronary artery were performed. Steroid therapy was started immediately after the operation. She recovered well and no complications was recognized after the operation.     

Aortitis syndrome with aortic regurgitation and bilateral coronary ostial stenosis

A 17-old-male was admitted to our hospital with the chief complaints of anterior chest oppression and syncope. His aortography showed severe aortic regurgitation with annular dilatation, and his coronary angiography revealed 90% stenosis of the left coronary ostium and total occlusion of the right coronary ostium. Because his symptoms increased in spite of steroid therapy during 2 weeks, aortic valve replacement with 25 mm SJM prosthetic valve and coronary artery bypass grafting using internal thoracic artery (IHA) and gastroepiploic artery (GEA) were performed at acute stage. Postoperative course was almost uneventful. Postoperative angiography showed graft patency and no evidence of perivalvular leakage. This is, to the best of our knowledge, the first report of coronary reconstruction using IHA and GEA for coronary disease associated with aortitis syndrome.     

A case of coronary artery bypass for bilateral coronary ostial stenosis in aortitis syndrome with occlusion of bilateral subclavian arteries]

A 52-year-old female with bilateral coronary ostial stenosis in aortitis syndrome underwent CABG. Vein grafts were used instead of arterial grafts, because of the occlusion of bilateral subclavian arteries. Proximal anastomosis of the grafts was performed after oval stomas larger than usual were created on the aortic wall to prevent late graft occlusion due to intimal proliferation of the aorta. On postoperative CAG, all grafts to RCA, LAD and Cx were patent. The patient left the hospital 3 weeks after surgery. We believe that CABG is preferable to the transaortic endarterectomy in the surgical treatment for coronary ostial stenosis associated with aortitis syndrome, because of the prevalence of technical difficulty and postoperative morbidity in the latter.     

Endarterectomy and graft replacement of severely calcified (porcelain) ascending aorta with coronary ostial involvement in a patient requiring aortic valve replacement.

We report a successful aortic valve replacement within an extensively calcified (porcelain) aorta, involving the left coronary artery ostium. Clamping such an aorta can result in embolization, dissection, and mural laceration. A 72-year-old female presented with a severely calcified and stenotic aortic valve with a peak pressure gradient of 101 mmHg. Computed tomography demonstrated extensive calcification of the ascending aorta. Coronary angiogram showed a 50% ostial left coronary artery stenosis. Under deep hypothermic circulatory arrest, the aorta was transected at the proximal arch and distal graft anastomosis was performed. This was followed by endarterectomy of the porcelain ascending aorta and the left coronary ostium. Aortic valve replacement, proximal aortic graft anastomosis, and a coronary artery bypass grafting (CABG) with the left internal thoracic artery (LITA) anastomosed to the left anterior descending artery (LAD) were then performed in a sequential manner.     

Bilateral coronary ostial stenoses with aortic regurgitation in a patient with syphilitic aortitis

Syphilitic aortitis is now rare in developed countries and is sometimes overlooked. A 61-year-old man with bilateral coronary ostial stenoses (#5:90%, #1:99%) and Sellers III/IV aortic regugitatioin (AR) induced by syphilitic aortitis presented with chest pain. Preoperative rapid plasma reagin titer and Treponema pallidum hemagglutination test were strongly positive, 256 fold and 191.25 C.O.I., respectively. Aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) with bilateral internal thoracic arteries (ITA) was performed successfully. The angiographic features as follows: 1) coronary artery stenosis is generally limited to the ostia, 2) the grade of stenosis is almost always more than 90%, 3) AR is frequently associated with coronary ostial stenosis. CABG should be performed with ITA, not saphenous vein grafts, to avoid occlusion of the ostium of the saphenous vein graft by syphilitic aortitis. Retrograde cardioplegia should be performed if ostial stenosis is severe.     

Coronary ostial stenosis after aortic valvuloplasty (comprehensive aortic root and valve repair)

Comprehensive aortic root and valve repair (CARVAR) surgery using specially designed aortic rings was introduced as a new surgical technique for aortic valve disease. We present five consecutive cases of iatrogenic coronary ostial stenosis after CARVAR surgery in patients with aortic stenosis. The preoperative coronary angiography confirmed that all the patients had normal coronary arteries. They underwent aortic valvuloplasty by aortic leaflet extension and insertion of specially designed inner and outer rings at the level of the sinotubular junction. Within 6 months after surgery, all the patients complained of resting chest pain and dyspnea with changes of electrocardiography. Repeated coronary angiography demonstrated right coronary artery (RCA) ostial stenosis in one patient and left main (LM) ostial stenosis in the other four patients. Intravascular ultrasonography demonstrated severe ostial stenosis and extensive echogenic tissue in the extravascular area. Four patients with LM ostial disease successfully underwent coronary bypass graft surgery, and percutaneous coronary intervention with stenting was performed in one case of RCA ostial stenosis. Because the mechanism of this complication is not fully confirmed, more clinical study is required to confirm the safety issues of CARVAR surgery.     

Aortocoronary bypass for coronary ostial stenosis following aortic valve replacement: a report of successfully treated case

A 62-year-old man underwent aortic valve replacement with a Medtronic-Hall valve (21 mm) for aortic stenosis and regurgitation with normal coronary arteries. An intermittent selective coronary perfusion with metal tip cannula was employed for both the coronary arteries. Postoperative course was uneventful. However, he began to complain of chest pain six months later. Cardiac catheterization and coronary arteriography revealed a normally functioning valve with 75% stenosis at the main trunk of the left coronary artery. Coronary bypass grafting using a saphenous vein was successfully performed to the left anterior descending coronary artery and the circumflex of the coronary artery. Whenever this fatal complication of the coronary ostial stenosis is recognized, earlier coronary revascularization should be recommended to save the severely ill patient.     

Surgical osteoplasty of the left main coronary artery using the right internal thoracic artery

A 39-year-old female with a history of progressive refractory angina required medical treatment. A coronary angiography showed 75% left coronary ostial stenosis without any other atherosclerotic lesions. The isolated ostial stenosis of the left main coronary artery was reconstructed by patch angioplasty, using a proximal segment of the right internal thoracic artery. The transaortic patch angioplasty was performed using a superior approach, which allowed a good exposure of the left coronary artery to the aorta without difficulty. A postoperative coronary angiography showed satisfactory patency, and a small biopsy of the ostial tissue demonstrated findings compatible with fibromuscular dysplasia. Based on this outcome, a proximal segment of the internal thoracic artery appears to provide a suitable patch material for enlarging the left coronary ostium.     

Coronary artery involvement in Takayasu's arteritis. Collective review and guideline for surgical treatment.

Coronary artery disease is a rare involvement of Takayasu's arteritis. From 1961 to 1989, 63 patients, including our five, have been reported to undergo operations for coronary artery disease resulting from Takayasu's arteritis. Most of the patients were Japanese (86%) and female (86%). The initial clinical manifestation was angina pectoris in 71%. Among 92 lesions, coronary ostia were most frequently involved (73%) followed by nonostial proximal lesions (18.5%). Forty-two of 62 (67.7%) ostial lesions of the left main coronary artery had more than 90%, or complete, stenosis. Aortic regurgitation was associated in 28 patients (44.4%). Myocardial revascularization was performed in 49, and transaortic endarterectomy in 12. Concomitant aortic valve replacement was done in 16 patients. Operative mortality was five (7.9%), and late deaths were reported in three patients. Postoperative steroid therapy was performed in 22. Operation was repeated in two patients because of graft failure. Thus coronary artery disease resulting from Takayasu's arteritis should be suspected in young Asian women with angina pectoris. The timing preferred for surgical intervention is during an inactive phase. Two procedures are commonly chosen for surgical intervention, either transaortic endarterectomy or coronary revascularization with vein grafts. Postoperative steroid therapy is strongly recommended to those patients who are operated on in the clinically or histologically active stage.     

Bicuspid aortic valve stenosis with single coronary artery.

A 56-year-old female with congestive heart failure was transferred to our institution. Aortography demonstrated aortic valve stenosis (AS) with a congenitally bicuspid valve and dilatation of the ascending aorta. Preoperative coronary angiography showed a left single coronary artery. Replacement of the aortic valve and ascending aorta was performed. She had an uneventful postoperative course. We report the case of aortic bicuspid valve stenosis with single coronary artery as an extremely rare congenital cardiac anomaly combination.     

Simultaneous repair of stenosis in coronary and vertebral arteries and aortic regurgitation secondary to Takayasu's aortitis

We report a case of severe stenosis in the ostium of both the coronary artery and the proximal left vertebral artery and severe aortic regurgitation secondary to Takayasu's aortitis. A 47-year-old woman underwent simultaneous repair consisting of aortic valve replacement, triple coronary artery bypass grafting, and aorto-left vertebral artery bypass. Saphenous vein grafts to 3 coronary arteries and the left vertebral artery were proximally anastomosed on a bovine pericardial patch in the ascending aorta. Since the patient had severe preoperative ischemic symptoms from vertebral-basilar insufficiency, we clamped the vertebral artery during reconstruction under deep hypothermic circulation. The postoperative course was uncomplicated. Simultaneous repair of such multiple lesions requires meticulous planning of surgical procedures and circulatory assist systems.     

Simultaneous repair of stenosis in coronary and vertebral arteries and aortic regurgitation secondary to Takayasu''s aortitis

We report a case of severe stenosis in the ostium of both the coronary artery and the proximal left vertebral artery and severe aortic regurgitation secondary to Takayasu's aortitis. A 47-year-old woman underwent simultaneous repair consisting of aortic valve replacement, triple coronary artery bypass grafting, and aorto-left vertebral artery bypass. Saphenous vein grafts to 3 coronary arteries and the left vertebral artery were proximally anastomosed on a bovine pericardial patch in the ascending aorta. Since the patient had severe preoperative ischemic symptoms from vertebral-basilar insufficiency, we clamped the vertebral artery during reconstruction under deep hypothermic circulation. The postoperative course was uncomplicated. Simultaneous repair of such multiple lesions requires meticulous planning of surgical procedures and circulatory assist systems.     

Cogan's syndrome with aortitis, aortic regurgitation, and aortic arch vessel stenoses

Cogan's syndrome of interstitial keratitis and vestibuloauditory dysfunction is rare. Systemic vasculitic manifestations occur, and 10% of patients with this syndrome have aortic valvular disease. A patient with Cogan's syndrome is presented who had aortitis of the ascending thoracic aorta, severe aortic valve regurgitation, orificial stenosis of the right coronary artery, and orificial stenoses of all three aortic arch vessels. Histopathology confirmed aortitis. Aortic valve replacement combined with coronary and aortic arch vessel reconstruction was required for correction.     

Left coronary ostial obstruction after aortic valve replacement with a supra-annular aortic valve

We report a rare case of left coronary ostial obstruction after aortic valve replacement with a Top Hat supra-annular aortic valve, which was diagnosed with intraoperative transesophageal echocardiography and successfully treated with an unplanned coronary bypass. The patient was a 76-year-old woman (height 143 cm, weight 44 kg) with aortic stenosis and regurgitation. A 19-mm Top Hat valve was implanted in the supra-annular position because of a small aortic annulus. There was a possibility that the high profile of this prosthesis might block the left coronary ostium. There may be a problem with the use of this prosthesis in patients with small and rigid aortic roots with little compliance. Although the Top Hat valve has a great advantage for small aortic annuli, care in its use should be taken due to possible interference with the coronary ostia. (Jpn J Thorac Cardiovasc Surg 2006; 54:199-202)     

Four cases of aortic valve replacement in aortitis syndrome]

Four surgically treated cases of aortic valve regurgitation associated with the aortitis syndrome were reported. All patients were female and ranged in age from 38 to 51 years. In two cases, obstructive lesions of the aortic arch branch were seen in aortograms. Three patients had no inflammatory findings at the operation and one was operated on after improvement of inflammatory findings by steroid therapy. Aortic regurgitation was caused by annuloaortic ectasia, and aortic valve replacement was performed by the everting mattress suture method in all cases. One patient with stenosis of the left carotid artery, occlusion of the left subclavian artery, and hypertension died of extended cerebral damage due to suspected low flow cerebral perfusion during cardiopulmonary bypass. The other three patients are doing well 4 months to 11 years after surgery without paravalvular leakage. In cardiac surgery for the aortitis syndrome with an obstructive lesion of the aortic arch branch, deep hypothermic and high flow cardiopulmonary perfusion is required to prevent ischemic brain complications during surgery.     

Aortic root replacement by cryopreserved homogrft for prosthetic valve detachment case due to aortitis

We present a surgical case of a 35-year-old man with aortitis. He had been performed the reconstruction of the right common carotid artery with a saphenous vein graft at 23 years old for his ruptured aneurysm by aortitis. The aortic valve replacement and CABG (LITA to LAD, SVG to D1 and SVG to RCA) were performed for aortic regurgitation and aneurysms of coronary arteries two years ago. The diastolic murmur was first heard at 18 months after the operation. The echocardiography on admission showed an abnormal movement of the prosthetic valve with perivalvular leakage. At the second operation, the valve dehiscence was observed. Although the tissues around the dehiscence was friable and edematous, there wre no signs of vegetation nor abscess formation. His aortic root was replaced with a cryopreserved aortic allograft conduit. His postoperative course was uneventful and aortography revealed neither aortic regurgitation nor stenosis of the coronary artery or SVGs. We think the softness of the allograft valve ring is favorable in valve detachment cases due to not only infection but also aortitis, to prevent redetachment.     

Left coronary ostial stenosis caused by syphilitic aortitis

We report 2 cases of cardiovascular disease related to end-stage syphilitic infection, which is now relatively rare. A 49-year-old man (case 1), and a 45-year-old man (case 2) were admitted to our hospital for angina pectoris. Cardiac catheterization showed severe aortic regurgitation and left coronary ostial stenosis. Active syphilis was detected in both cases by routine blood examination on admission. Oral ampicillin was started immediately to treat the syphilis; however, during the course of treatment, acute heart failure developed in both patients. We performed emergency aortic valve replacement and coronary artery bypass grafting. Intraoperatively, the orifice of the left coronary artery was almost occluded, and retrograde perfusion of cardioplegia was needed to induce cardiac arrest. Both patients recovered uneventfully. When treating patients with antibiotics for syphilitic disease, it is important to prepare for the possibility of urgent surgery.     

Iatrogenic left main and proximal right coronary artery stenoses after aortic valve replacement.

Iatrogenic left main coronary artery stenosis after aortic valve replacement is an infrequent but potentially life-threatening complication. A 44-year-old woman who had normal coronary arteries documented by preoperative coronary angiogram, and who developed severe stenosis of the left main coronary artery and subtotal occlusion of the proximal right coronary artery after aortic and mitral valve replacements is presented. Coronary lesions were clinically manifested 4 months after the first operation. Accurate diagnosis was confirmed by repeat coronary angiography. She underwent successful coronary artery bypass grafting.     

Takayasu's arteritis mimicking acute aortic dissection

A 17-year-old girl presented with a history of dyspnea on exertion and fever of 1-week duration. She was evaluated elsewhere with transesophageal echocardiography and helical computed tomographic scan, and she had been diagnosed with an acute type I dissection of the aorta. She had also been diagnosed with severe aortic regurgitation and a suspected aortic root abscess. On the operating table, we found no evidence of dissection, but we did find that her aorta was severely thickened and inflamed. The patient's aortic valve was replaced. In view of the left main stem ostial stenosis, we harvested and grafted the left internal thoracic artery to the left anterior descending artery. During the operation it is of paramount importance to rule out dissections involving the arch and coronary ostial narrowing.