Iatrogenic ostial stenosis of the left coronary artery. Report of a case with Starr-Edwards aortic prosthesis (author's transl)

A case of a 41 years-old-man, who had undergone surgical intervention ten years previously for aortic valve replacement in ECC with the coronary perfusion technique, is reported. This patient was studied because of the appearance of angina pectoris three months after the intervention and its progressive development. Selective left coronary angiography showed an ostial subocclusive stenosis; the run-off from the right coronary artery provided distal blood supply to the left coronary artery. A venous bypass was implanted between the aorta and the left anterior descending branch; the prosthesis was substituted because it was altered and caused hemolysis' problems. In accordance with most Authors late ostial coronary stenosis is a complication of the coronary perfusion technique, which is adopted for myocardial protection during surgical interventions for aortic valve replacement.     

Angioplasty, stenting and thrombectomy to correct left main coronary stem obstruction by a bioprosthetic aortic valve

Iatrogenic ostial coronary stenosis is a rare life-threatening complication of aortic valve replacement, usually presenting after 2-6 months. Although it is rarely reported, its incidence has been estimated at 0.3-5%. The most likely mechanism is posttraumatic fibrous intimal proliferation caused by coronary ostia cannulation for direct cardioplegia. We report a unique case of early occurrence of thrombotic obstruction of the left main stem following aortic valve replacement and its interventional management.     

Long-term course of syphilitic aortic insufficiency with ostial stenosis following surgical treatment

Syphilitic aortic insufficiency and coronary ostial stenosis is a rare condition. It was diagnosed in 8 patients referred for surgery. The infection, acknowledged in 3 cases, was contracted over 15 years prior to admission! The operative indication was aortic valve replacement in 6 cases (Stage II to IV dyspnoea) and coronary insufficiency in 2 cases (Stage III angina pectoris). Two cases of ostial stenosis were not identified at coronary angiography, illustrating the potential diagnostic pitfall of a disease which is often unrecognised nowadays. Preoperative echocardiography of the left main coronary artery, especially its intra-aortic segment, may be of value but was not performed in these old cases. Surgery consisted in aortic valve replacement and coronary revascularisation by decortication of the ostia or coronary bypass (1 case). The evolution was excellent in the 6 survivors, especially with respect to the anginal syndrome which was completely cured without associated treatment. A protocol of echocardiographic surveillance of the left main coronary artery has been instituted in these patients to detect any late postoperative changes after ostial decortication.     

Bilateral ostial coronary stenosis and rheumatic aortic valve stenosis

A 49-year-old patient presented with angina pectoris and clinical findings of aortic valve stenosis and regurgitation. Rheumatic aortic valve stenosis and regurgitation was diagnosed on echocardiography. Coronary angiography findings showed severe calcification in the aorta root with right coronary ostial occlusion, and were suggestive of left main ostial stenosis and proximal main stem stenosis, which was confirmed on CT angiography. Curvilinear calcification of the aorta was present on CT angiography. The findings suggested syphilitic aortitis. Syphilis serology was positive (RPR titre 1/16). The angina was caused by severe coronary ostial disease likely due to syphilitic aortitis and exacerbated by the rheumatic aortic valve stenosis and regurgitation.     

Coronary Ostial Stenosis after Aortic Valve Replacement: Successful Treatment of 2 Patients with Drug-Eluting Stents

Coronary ostial stenosis is a rare but potentially serious sequela after aortic valve replacement. It occurs in the left main or right coronary artery after 1% to 5% of aortic valve replacement procedures. The clinical symptoms are usually severe and may appear from 1 to 6 months postoperatively. Although the typical treatment is coronary artery bypass grafting, patients have been successfully treated by means of percutaneous coronary intervention.Herein, we present the cases of 2 patients in whom coronary ostial stenosis developed after aortic valve replacement. In the 1st case, a 72-year-old man underwent aortic valve replacement and bypass grafting of the saphenous vein to the left anterior descending coronary artery. Six months later, he experienced a non-ST-segment-elevation myocardial infarction. Coronary angiography revealed a critical stenosis of the right coronary artery ostium. In the 2nd case, a 78-year-old woman underwent aortic valve replacement and grafting of the saphenous vein to an occluded right coronary artery. Four months later, she experienced unstable angina. Coronary angiography showed a critical left main coronary artery ostial stenosis and occlusion of the right coronary artery venous graft. In each patient, we performed percutaneous coronary intervention and deployed a drug-eluting stent. Both patients were asymptomatic on 6-to 12-month follow-up. We attribute the coronary ostial stenosis to the selective ostial administration of cardioplegic solution during surgery. We conclude that retrograde administration of cardioplegic solution through the coronary sinus may reduce the incidence of postoperative coronary ostial stenosis, and that stenting may be an efficient treatment option.Key words: Angioplasty, transluminal, percutaneous coronary; aortic valve/surgery; cardiac surgical procedures/adverse effects; coronary artery disease/etiology/prevention & control; coronary stenosis/diagnosis/etiology/therapy; heart valve prosthesis implantation/adverse effects; iatrogenic disease/prevention & control; perfusion/adverse effects/instrumentation; postoperative complications/therapy; treatment outcomeCoronary ostial stenosis is a rare but potentially serious postoperative sequela of aortic valve replacement (AVR). Ostial stenosis can occur in the left main coronary artery (LMCA) or in the right coronary artery (RCA). The condition, first described by Roberts and Morrow in 1967,¹ is believed to occur after 1% to 5% of AVR procedures.^2–7 No underlying cause has been determined. The clinical symptoms of coronary ostial stenosis are usually severe and can appear from 1 to 6 months postoperatively.^8,9 Although the typical treatment is coronary artery bypass grafting (CABG), patients have been successfully treated by means of percutaneous coronary intervention (PCI).^10–15 Herein, we present the cases of 2 patients in whom coronary ostial stenosis developed after AVR, discuss their PCI treatment, and offer our conclusion regarding the feasibility of PCI in the treatment of coronary ostial stenosis.     

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.     

Bilateral ostial coronary stenosis and rheumatic aortic valve stenosis

A 49‐year‐old patient presented with angina pectoris and clinical findings of aortic valve stenosis and regurgitation. Rheumatic aortic valve stenosis and regurgitation was diagnosed on echocardiography. Coronary angiography findings showed severe calcification in the aorta root with right coronary ostial occlusion, and were suggestive of left main ostial stenosis and proximal main stem stenosis, which was confirmed on CT angiography. Curvilinear calcification of the aorta was present on CT angiography. The findings suggested syphilitic aortitis. Syphilis serology was positive (RPR titre 1/16). The angina was caused by severe coronary ostial disease likely due to syphilitic aortitis and exacerbated by the rheumatic aortic valve stenosis and regurgitation.     

Concomitant aortic valve replacement and surgical angioplasty of left main coronary ostium

The association of calcific aortic valve disease and isolated coronary ostial stenosis is rare. A 80-year-old woman was found to have severe aortic stenosis with critical narrowing of the ostium of the left main coronary artery. She was successfully managed by simultaneous aortic valve replacement and patch angioplasty of the left main coronary artery, using a patch of autologous pericardium fixed in glutaraldehyde. Angiographic control at 1 month coupled with intravascular echographic imaging showed adequate relief of the ostial stenosis and patency of the left main trunk.     

Cardiac computed tomography in the management of iatrogenic coronary ostial stenosis after aortic valve replacement

Although rare, iatrogenic coronary ostial stenosis is an important complication of aortic valve replacement and Bentall procedure. We report a 32-year-old male presenting an acute coronary syndrome post-Bentall procedure and the role of computed tomography in diagnosis and management of iatrogenic coronary ostial stenosis. Such occlusions are commonly identified in the left main coronary artery, but can develop in venous bypass grafts at anastomoses with Dacron aortic grafts. Cardiac computed tomography is valuable to exclude noncoronary causes of chest pain, assess ostial stenosis of manipulated arteries post reimplantation, and shed light on mechanisms and management of these lesions.     

Congenital ostial left main coronary artery stenosis associated with a bicuspid aortic valve in a young woman

We describe a 41-year-old woman with no cardiac risk factors, typical exertional angina and an abnormal noninvasive stress test. Coronary angiography demonstrated an ambiguous left main coronary artery (LMCA) stenosis. Intravascular ultrasound (IVUS) demonstrated no atheroma, but the minimum lumen diameter and area of the ostial LMCA were significantly reduced. Transesophageal echocardiography showed normal left ventricular function with a bicuspid aortic valve. Two-vessel coronary artery bypass grafting was subsequently performed. To our knowledge, this is the first IVUS-documented case of a congenital left main coronary artery stenosis associated with a bicuspid aortic valve.     

An unusual cause of disabling angina following aortic valve replacement

Severe ostial stenosis of the coronary arteries following aortic valve replacement is a potentially lethal complication. The usual presentations are recent onset of severe angina, ventricular arrhythmias, congestive heart failure, and sudden death. It is generally accepted to arise from injury to the coronary arteries during direct cannulation and continuous perfusion of cardioplegia under high pressure during operation. We report on a patient who developed critical left coronary ostial stenosis after aortic valve replacement. The cause for the stenosis was probably related to the over-sizing and orientation of the prosthesis. The prosthesis was replaced and patch angioplasty of the left coronary ostia performed. The patient was well with normal coronary anatomy three years after surgery.     

Main branch stenosis following aortic valve replacement

Three patients developed left main stem stenosis within some months after aortic valve replacement. In all of them diagnosis was confirmed by angiography and bypass surgery was performed successfully. Left main stem stenosis is a rare complication of aortic valve replacement and is due to cannulation and perfusion of the coronary arteries. The mechanism is probably injury of the vessel wall due to the perfusion-catheter, followed by intimal hyperplasia. A similar mechanism is assumed for restenosis after transluminal coronary angioplasty.     

Subacute bilateral coronary ostial stenoses following cardiac catheterization and PTCA

Accelerated coronary ostial stenosis is an infrequent late complication of coronary artery catheter instrumentation during aortic valve surgery, PTCA, or coronary angiography. We report the first case of bilateral coronary artery ostial stenoses developing after cardiac catheterization and right coronary artery PTCA. In patients with worsening angina following cardiac catheterization or PTCA, accelerated ostial stenoses should not be over-looked in the differential diagnosis.     

Iatrogenic left main coronary ostial stenosis after a bentall procedure in an asymptomatic young man

Coronary ostial stenosis is a rare but potentially fatal sequela of aortic surgery. The clinical presentation can include acute coronary syndromes, ventricular arrhythmias, congestive heart failure, or sudden death. Herein, we present what we believe is the first reported case of asymptomatic iatrogenic left main coronary ostial stenosis. The patient was an active 34-year-old man who had undergone a modified Bentall procedure and was asymptomatic thereafter. Seven months after that operation, exercise stress testing showed electrocardiographic signs of asymptomatic myocardial ischemia at high workload, and coronary angiography revealed severe nonatherosclerotic left main ostial stenosis. Percutaneous coronary intervention and stenting of the unprotected left main stenosis was successful, and patency at 8 months was apparent on coronary angiography.The conventional treatment for coronary ostial stenosis, coronary artery bypass grafting, carries a high risk of perioperative infarction, morbidity, and death. We found that percutaneous coronary intervention with stenting yielded positive short- and long-term results and may provide an alternative to cardiac surgery in these high-risk patients. We recommend that physicians evaluate even asymptomatic patients for left main coronary ostial stenosis after aortic surgery so that early diagnosis and treatment can avert severe clinical manifestations.     

Percutaneous treatment of left main coronary stenosis as a late complication of bentall operation for acute aortic dissection.

Severe ostial left main coronary stenosis developed 35 days after successful Bentall-type operation for acute aortic dissection. Treatment of this kind of complication is usually performed with open chest coronary artery bypass grafting. In our case, treatment with percutaneous transluminal coronary angioplasty and stenting of the lesion immediately after diagnostic coronary angiography was performed successfully, with persisting good results at 9-month clinical follow-up.     

A case of left coronary ostial obstruction due to syphilitic aortitis

Coronary ostial stenosis is a rare lesion, which is a complication of syphilitic aortitis, Takayasu's aortitis, aortic valve disease, and familial hypercholesterolemia. We present a case of left coronary ostial obstruction due to syphilitic aortitis. A 67 years old man was admitted to our hospital for evaluation of a ten year history of angina on exertion. On physical examination, the only abnormal finding was a grade 2/6 high-pitched diastolic murmur. Coronary risk factor was not detected from biochemical results, but both the TPHA and FTA-ABS test were positive. Treadmill stress test showed more than 2 mm ST segment depression associated with chest pain. Coronary angiography revealed complete obstruction of left coronary ostium with good collaterals from the right coronary artery. The coronary arterial tree was otherwise normal. Furthermore, aortagraphy showed a moderate degree of aortic regurgitation. From the examination of previous reports including our own case, we think that the angiographic features of syphilitic coronary ostial stenosis can be summarized as below. 1. Coronary artery stenosis is generally limited to the ostium. 2. The grade of stenosis almost always shows more than 90% stenosis, and sometimes bilateral coronary ostium can be affected. 3. Aortic regurgitation is frequently noted, associated with coronary ostial stenosis.     

Bilateral coronary ostial stenoses post-Bentall procedure: management options in the DES era

The Bentall procedure for aortic root and valve replacement with coronary reimplantation was initially described in 1968. This procedure is considered the "gold standard" for treatment of combined valve and ascending aortic pathology. The procedure is performed most commonly in patients with degenerative aortic disease, including atherosclerotic disease, ectasia and poststenotic aortic dilatation. The complication of single coronary ostial stenosis following reimplantation is extremely rare in this procedure, occurring in less than 2% of patients. We describe the first case of bilateral coronary ostial stenoses following the Bentall procedure in a patient with documented heparin-induced thrombocytopenia (HIT) that was successfully treated with percutaneous coronary intervention (PCI).     

Bilateral coronary ostial stenosis after aortic valve replacement with freestyle stentless bioprosthesis: a case report

An 80-year-old woman underwent aortic valve replacement with Freestyle stentless prosthetic valve for the stenosis. Four months later, she was admitted with myocardial ischemia. Coronary angiography revealed severe stenosis in the ostium of both right and left coronary arteries. Coronary artery bypass grafting was performed. One year later, percutaneous coronary intervention was carried out for the bilateral coronary arteries because of unstable angina. Intravascular ultrasonography demonstrated localized, membranous, homogeneous, and severe stenoses in the ostium of the right and left coronary arteries. Histological examination of a specimen taken by directional coronary atherectomy showed intimal hypertrophy, mucinous degeneration, and hyaline degeneration without reactive change. There were no findings of atherosclerosis. These clinical, angiographical histological and intravascular ultrasonography findings suggest that the immunological reaction to the heterograft was the mechanism of the bilateral ostial coronary arteries stenoses in the present case. The possibility of immunological reaction after aortic valve replacement with heterograft should be considered. There have been no report on intravascular echocardiographic and histological findings.     

Ostial left main stenosis due to takayasu arteritis: multimodality imaging and surgical ostioplasty

Takayasu's arteritis is an inflammatory process, involving larger blood vessels-namely the aorta and its branches. The majority of these patients present with symptoms of vascular obstruction. We report a case of a 38-year-old Chinese female who presented with one month history of angina pectoris as the initial manifestation. Coronary angiography showed 99% ostial left main coronary stenosis. The diagnosis was first suspected in the operating room by TEE and subsequently supported by laboratory studies and aortic biopsy. The technique of myocardial revascularization was altered and she underwent patch ostioplasty of the left main coronary artery and aortic valve repair to correct aortic regurgitation.     

Treatment of obstructive aortic atheroma in homozygotic familial hypercholesterolemia

The object of this report is to describe the surgical treatment of a rare clinical form of homozygotic familial hypercholesterolaemia (HFH) associating valvular and supravalvular stenosis with coronary ostial stenosis. Three patients, two male and one female, aged 15, 23 and 41 respectively, suffering from HFH diagnosed in early childhood, presented with obstacles to left ventricular ejection and myocardial ischaemia due to coronary ostial stenosis. Surgery consisted of corrections in a single procedure of all abnormalities by aortic valve replacement, ascending aortic replacement and widening of the coronary artery ostia which were reimplanted on the aortic tube. The postoperative course of all three patients was favourable. Postoperative echocardiography showed the normal position of the valvular prosthesis, normalisation of the left ventricular ejection fraction with no significant residual obstruction. Angioscan of the coronary arteries showed a good result of coronary ostial widening. The authors conclude that HFH is a rare condition and that disease of the ascending aorta is common in this variety with involvement of the aortic valve, the ascending aorta and the coronary ostia. The surgical procedure described by the authors allows correction of all the abnormalities with the hope of a good long-term result.