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.     

Iatrogenic coronary artery stenosis following aortic valve replacement.

Until recnetly, coronary arterial perfusion was one of the best methods to protect myocardium during aortic valve replacement. However, the insertion of perfusion cannulas may produce immediate traumatic lesions and late stenosis of the coronary arteries, with grave consequences. Two patients with normal coronary arteries prior to operation developed obstruction of the maximal left main coronary artery following aortic replacement. One of these patients represents the first case of iatrogenic coronary arterial stenosis in which the aortic valve was replaced with a porcine bioprosthesis. Accelerating angina pectoris and ventricular arrhythmias were the presenting clinical manifestations. Aorta-coronary bypass grafting to the left anterior descending and circumflex coronary arteries was successfully performed in one patient, while the other patient died before investigative procedures could be undertaken. Any patient whose aortic valve has been replaced and who develops angina pectoris a few months after operation should be suspected of having developed stenosis of the proximal coronary artery. Coronary angiography should be perfomed promptly. Once the lesion is recognized, the operaiton should be performed posthaste because these lesions are life threatening owing to their proximal location and rapid evolution.     

Successful combined minimally invasive direct coronary artery bypass and transapical aortic valve implantation

Transapical aortic valve implantation is indicated in high-risk patients with aortic stenosis and peripheral vascular disease requiring aortic valve replacement. Minimally invasive direct coronary artery bypass grafting is also a valid, minimally invasive option for myocardial revascularization in patients with critical stenosis on the anterior descending coronary artery. Both procedures are performed through a left minithoracotomy, without cardiopulmonary bypass, aortic cross-clamping, and cardioplegic arrest. We describe a successful combined transapical aortic valve implantation and minimally invasive direct coronary bypass in a high-risk patient with left anterior descending coronary artery occlusion and severe aortic valve stenosis.     

Successful surgical management for aortic and mitral stenosis in homozygous familial hypercholesterolemia: a case report

A 72-year-old woman with a known history of homozygous familial hyperlipidemia (IIa) was referred to our hospital for an operation necessitated by aortic and mitral stenosis and paroxysmal atrial fibrillation. Computed tomography and cardiac catheterization revealed a heavily calcified aortic root and mitral annulus as well as a high-grade stenosis of the left anterior descending and right coronary arteries. Double aortic and mitral valve replacement concomitant with replacement of ascending aorta, maze III procedure, and coronary artery bypass were performed. Temporary hypothermic arrest was employed to reduce the risk of cerebral emboli.     

Incidental dual source computed tomography imaging of ductal aortic coarctation, left subclavian artery stenosis and bicuspid aortic valve in a patient admitted for atypical chest pain

A case of incidental ductal aortic coarctation with left subclavian artery stenosis at the origin, severely calcified and stenotic bicuspid aortic valve, and normal coronary arteries demonstrated by single breath hold dual source computed tomography angiography in a 46-year-old man admitted for acute chest pain is presented.     

Left Main Coronary Artery and Supravalvular Aortic Stenosis in Adult: Treatment with Ostial Patchplasty and Modified Brom Procedure

Abstract   Left main coronary artery (LMCA) stenosis accompanying to supravalvular aortic stenosis is a very uncommon, serious congenital abnormality. Aortic valve leaflet fusions and intimal thickening of the aortic valve leaflets and coronary artery are the underlying pathologies for the LMCA stenosis. We operated on a 21-year-old male patient for supravalvar aortic stenosis with LMCA ostial stenosis. We enlarged the LMCA with a pericardial patch (ostial plasty) and reconstructed the aortic root with a modified Brom procedure. Postoperative course was uneventful; echocardiographic evaluation revealed a normal functioning aortic valve with a normal left ventricular function. Gradient at left ventricular outflow tract was decreased a great deal. Although supravalvular aortic stenosis with LMCA stenosis is a very rare congenital abnormality, this clinical entity can be successfully corrected with detailed and selected surgical procedures.     

A case of aortitis syndrome with left coronary ostial stenosis and aortic regurgitation treated by transaortic coronary endarterectomy and aortic valve replacement

A case, 23-year-old female of aortitis syndrome with left coronary ostial stenosis and aortic regurgitation was reported. The coronary angiography showed critical stenosis of the left coronary ostium with intact main stem and its branches. The aortogram revealed aortic regurgitation of grade III, and multiple obstructive or stenotic lesions on the left common carotid artery, the origin of the left renal artery, the inferior mesenteric artery and the abdominal aorta. After improvement of inflammatory findings by steroid therapy during 2 months, transaortic coronary endarterectomy and aortic valve replacement with 21 mm Bj?rk-Shiley valve were performed successfully. Postoperative course was uneventful. Coronary angiography performed at the 57th day after the operation showed complete removal of the left coronary ostial stenosis, and aortography showed no evidence of perivalvular leakage of the aortic valve prosthesis. The indication of transaortic coronary endarterectomy and the technique used to avoid aortic valve detachment which may be caused by recurrence of aortitis were discussed in this paper.     

Transcatheter aortic valve replacement in patients with anomalous left circumflex coronary artery

The anomalous left circumflex artery can be a risk for coronary stenosis or obstruction during transcatheter aortic valve replacement; however, the best procedural management has not been clarified. We describe three patients with severe aortic valve stenosis as well as anomalous left circumflex artery. In the first patient, a coronary guidewire with balloon was placed before deploying a SAPIEN 3 transcatheter heart valve, as protection from the coronary occlusion or stenosis. For the second and third patients, no coronary protection was used. All procedures were completed safely and no complications were detected at one‐year follow‐up.     

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.     

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.     

Iatrogenic left main coronary artery stenosis following aortic valve replacement: two cases report

Two cases of iatrogenic left main coronary artery stenosis (ICOS) following aortic valve replacement (AVR) are documented. The first patient began to have chest pain due to myocardial ischemia 7 months after AVR. Angiographically, the ostium of her left coronary artery was severely stenotic. She refused coronary bypass grafting. She died of myocardial infarction due to ICOS, 23 months after AVR. Histologically, a loose cellular connective tissue was found around the stenotic coronary arterial lumen. The other patient had chest pain 4 months after aortic and mitral valve replacement. The ICOS was diagnosed angiographically. After she had coronary bypass grafting, she was free from myocardial ischemic symptoms. The onset of myocardial ischemic symptoms in the first six months after AVR is highly suggestive of ICOS, and urgent coronary angiography is recommended and, if proximal stenosis of the coronary arteries is diagnosed, coronary bypass grafting should be performed.     

Coronary flow velocity waveforms in aortic stenosis and the effects of valve replacement

In 6 patients with pure aortic stenosis, the flow velocity waveforms in the left anterior descending coronary artery were studied using an 80-channel 20-MHz pulsed Doppler velocimeter before and immediately after aortic valve replacement. All patients showed normal coronary arteriograms. The left anterior descending coronary artery flow velocity waveform in aortic stenosis was characterized by a reverse flow in the first half of systole and a slowly increasing diastolic inflow. After aortic valve replacement, the reverse flow in the first half of systole disappeared in all patients, but an end-systolic reverse flow was discerned in 5 of 6 patients. The increasing rate of the diastolic inflow was augmented in all patients. After aortic valve replacement, the time from onset of diastole to the diastolic peak velocity was shortened from 176.8 +/- 28.8 to 90.5 +/- 18.8 ms (p less than 0.01), and the diastolic peak velocity increased from 90.5 +/- 28.0 to 122.5 +/- 17.2 cm/s (p less than 0.05). Blood pressure and heart rate, however, did not change significantly before and after valve replacement. These changes in the left coronary artery velocity waveforms after valve replacement suggest the beneficial effects of removal of aortic stenosis on human coronary artery inflow.     

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.     

A case of lateral origin of the left internal mammary artery

A 66 years old men, with left anterior descending coronary artery (LAD) stenosis and aortic valve stenosis, underwent coronary artery bypass grafting (CABG) to LAD with left internal mammary artery (LIMA) and aortic valve replacement. His postoperative course was uneventful. But, postoperative angiogram showed that his patent LIMA graft was originated from much lateral side of the left subclavian artery. Internal mammary artery is considered the most ideal graft for CABG, but its' anomality is not well known. We present this rare case with the anomalous origin of LIMA.     

Atherosclerosis in type IV dual left anterior descending artery and anomalous aortic origin of the left circumflex artery in association with rheumatic valve disease: a case report

Double left anterior descending coronary artery arising from the left and right coronary arteries is a very rare congenital coronary artery anomaly. In this case, there was also a circumflex artery arising from the right sinus Valsalva and in association with severe rheumatic valve disease. Subsequently, the patient underwent mechanical aortic valve replacement with a 21-mm bileaflet mechanical aortic valve and coronary artery bypass grafting. We performed coronary artery bypass grafting of 3 vessels, including the left internal mammary artery to the large diagonal branch and the saphenous vein graft to the circumflex artery and the right coronary artery, under cardiopulmonary bypass. In this report, we describe an unusual case of this combination in association with both atherosclerosis and rheumatic aortic and mitral valve disease.     

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.     

Combined off-pump transapical transcatheter aortic valve implantation and minimally invasive direct coronary artery bypass

Transcatheter aortic valve implantation has been shown to be an effective treatment for severe aortic stenosis in high-risk surgical patients. Many of these patients have significant coexisting coronary artery disease. We report the first case of combined off-pump transapical aortic valve implantation and minimally invasive direct coronary artery bypass via a left mini-thoracotomy in an 82-year-old man with significant comorbidities. This combined procedure is technically feasible and can be performed safely in selected patients with aortic stenosis and left anterior descending artery lesion that is not suitable for percutaneous intervention.     

Surgical Management of Supravalvar Aortic Stenosis with Coronary Artery Involvement

Abstract Supravalvar aortic stenosis is characterized by an obstruction of the left ventricular outflow tract distal to the aortic valve. Its association with left main coronary artery stenosis is well known but right coronary artery involvement has not been reported. We describe two cases of supravalvar aortic stenosis with coronary artery stenosis and its surgical management . (J Card Surg 2012;27:678‐681)     

Aortic root replacement with anomalous origin of the coronary arteries

Coronary arteries with anomalous origin from the aorta can be at risk during aortic valve procedures. We report a case of origin of the circumflex and left coronary artery from the proximal right coronary artery in a patient with a bicuspid aortic valve and aortic root aneurysm. Attention to the anatomic relationship of the anomalous arteries to the aorta allowed safe aortic root replacement.     

Occlusion of left coronary ostium with a rudimentary aortic cusp

A 74-year-old woman with exertional angina was diagnosed with occlusion of the left coronary ostium associated with a rudimentary aortic valve cusp. A transesophageal echocardiogram, a multi-detector computed tomographic scan, and a coronary angiographic scan revealed the rudimentary aortic cusp covering the small left coronary aortic sinus leading to occlusion of the ostium of the left coronary artery, despite the intact coronary arteries. After excision of the rudimentary left coronary cusp, the left coronary ostium appeared intact. An aortic valve replacement with annular enlargement using a bioprosthetic valve was performed. The patient uneventfully recovered without angina.