Percutaneous treatment of the left main coronary artery ostial obstruction following aortic valve replacement.

Iatrogenic left main coronary artery ostial stenosis is a rare and late life-threatening complication of aortic valve replacement. The exact causes of this critical condition, despite being still nowadays elusive, are possibly related to the insertion of perfusion catheters into the left coronary system for cardioplegia delivery. We describe the case of a 69-year-old man, with normal coronary arteries documented by preoperative coronary angiography before surgery, who developed 1 year after aortic valve replacement worsening effort angina. A second coronary angiography revealed a severe left main ostial stem stenosis, which was successfully treated by sirolimus-eluting stent deployment. This case demonstrates a new percutaneous approach of this poorly understood, yet potentially fatal complication following aortic valve replacement.     

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.     

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.     

Technical considerations in patients undergoing combined aortic valve replacement and aortocoronary bypass surgery.

Forty-nine patients have undergone combined aortic valve replacement and aortocoronary saphenous vein bypass graft surgery using a technique of distal coronary perfusion. Vein grafts are placed before replacement of the aortic valve, and continuously perfused by siting the proximal anastomoses high on the aortic root or individually perfusing the grafts before proximal anastomosis. Continuous coronary ostial perfusion is used as well during aortic valve replacement. There were 3 (6.1%) operative deaths and 1 (2%) perioperative myocardial infarction. A comparison of this technique with other reported results suggests that attention to myocardial perfusion distal to significant coronary artery stenosis may decrease the incidence of perioperative myocardial infarction in patients requiring both aortic valve replacement and coronary bypass graft operation.     

Technical considerations in patients undergoing combined aortic valve replacement and aortocoronary bypass surgery.

Forty-nine patients have undergone combined aortic valve replacement and aortocoronary saphenous vein bypass graft surgery using a technique of distal coronary perfusion. Vein grafts are placed before replacement of the aortic valve, and continuously perfused by siting the proximal anastomoses high on the aortic root or individually perfusing the grafts before proximal anastomosis. Continuous coronary ostial perfusion is used as well during aortic valve replacement. There were 3 (6.1%) operative deaths and 1 (2%) perioperative myocardial infarction. A comparison of this technique with other reported results suggests that attention to myocardial perfusion distal to significant coronary artery stenosis may decrease the incidence of perioperative myocardial infarction in patients requiring both aortic valve replacement and coronary bypass graft operation.     

Takayasu arteritis with multiple cardiovascular complications

A 60-year-old Japanese woman first presented in 1990 with effort angina. She underwent coronary angiography and was diagnosed with bilateral coronary ostial stenosis and Takayasu arteritis. Coronary artery bypass graft surgery (CABG) for multiple vessels was attempted, but the blood flow in the bilateral internal thoracic and gastroepiploic arteries was to poor for a donor artery, and the calcification of the ascending aortic wall was too severe for anastomosis of saphenous vein grafts. Therefore, the proper hepatic artery was connected to the left anterior descending artery using a vein graft. In April 2000, the patient's angina worsened. Occlusions of both subclavian arteries, bilateral coronary ostial stenosis and vein graft occlusion, aortic valve regurgitation, and two severe stenoses of the descending aorta were observed. Aortic valve replacement, and coronary and aorta revascularization were desirable, but the severe aortic wall calcification and thickening rendered these interventions impossible. Treatment with medication was chosen. The patient was discharged without severe angina. A combination of these serious cardiovascular complications which do not allow any surgical intervention is very rare. Received: May 21, 2001 / Accepted: August 24, 2001     

Atypical cause of hibernating myocardium due to complex cardiovascular lesions associated with Takayasu's arteritis

Myocardial hibernation is recognised as chronic hypoperfusion of the myocardium and its functional recovery after surgical revascularisation has been described. A case of surgery for complex lesions including severe aortic valve regurgitation, coronary ostial stenosis, and aortic calcification (porcelain aorta) caused by Takayasu's arteritis is presented. The onset of left ventricular functional improvement after aortic valve replacement and coronary revascularisation were indicative of preoperative atypical myocardial hibernation caused by aortic valve disease and coronary artery disease associated with Takayasu's arteritis.     

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.     

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.     

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 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.     

Percutaneous aortic valvuloplasty as a bridge to a high-risk percutaneous coronary intervention

We describe a novel approach of using percutaneous aortic valvuloplasty as a bridge to percutaneous coronary intervention in a patient with refractory congestive heart failure, severe aortic stenosis, severe left ventricular dysfunction and severe 3-vessel coronary artery disease who was not a surgical candidate for aortic valve replacement and coronary artery bypass grafting.     

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.     

Mid-Term Outcome of Surgical Coronary Ostial Plasty: Our Experience

Abstract The conventional coronary artery bypass procedure that uses venous or arterial conduit for isolated critical stenosis of the left main coronary artery (LMCA) restores a less physiological perfusion of the myocardium and uses an appreciable length of bypass material, Coronary ostial plasty has been described as an alternative surgical technique in proximal obstructive coronary artery disease without calcifications. Here we report 23 patients (15 males and 8 females aged 37–78 years; mean age 57 years) who underwent surgical ostial plasty. Ostial reconstruction with fresh pericardial patch was performed in all patients: 15 patients with LMCA stenosis, 6 patients with right coronary (RC) ostial stenosis. and 2 patients with both RC artery and LMCA stenosis. In seven cases, coronary artery bypass grafting was added for contralateral distal stenosis with a total of five arterial conduits and six venous grafts. One patient died; the ostial plasty and grafts were patent at necropsy. Thal-lium-201 myocardial scintigraphy under stress at 30 days to 6 months after operation demonstrated good myocardial perfusion in 21 of 22 patients. Coronary angiography at follow-up (49 ± 8 months) demonstrated good surgical ostial plasty results in 21 of 22 patients and good coronary flow in 19 of 22 patients; angiographic study at mid-term follow-up revealed only one failure of the surgical ostial plasty technique associated with venous graft obstruction. In 2 other patients CABG failure due to venous graft obstruction (1 patient) or distal stenotic lesions of the left coronary artery (1 patient) was noted. The overall successful outcome of the surgical ostial plasty was 22 of 23. We believe that surgical angioplasty of the coronary ostia may be used in the presence of proximal noncalcified obstructive lesions as an alternative technique, which offers a more physiological revascularization; it also spares grafting material and allows subsequent percutaneous transluminal angioplasty or coronary artery bypass surgery. (J Card Surg 7999; 14:294–300)     

Apico-Aortic Conduit for severe aortic stenosis: Technique,applications, and systematic review

Patients referred for aortic valve replacement are often elderly and may have increased surgical risk associated with ascending aortic calcification, left ventricular dysfunction, presence of coronary artery disease, previous surgery, and/or presence of several co-morbidities. Some of these patients may not be considered candidates for conventional surgery because of their high risk profile. While transcatheter aortic valve replacement constitutes a widely accepted alternative, some patients may not be eligible for this modality due to anatomic factors. Apico-Aortic Conduit (AAC) insertion (aortic valve bypass surgery) constitutes a possible option in those patients. Apico-Aortic Conduit is not a new technique, as it has been used for decades in both pediatric and adult populations. However, there is a resurging interest in this technique due to the expanding scope of elderly patients being considered for the treatment of aortic stenosis. Herein, we describe our surgical technique and provide a systematic review of recent publications on AAC insertion, reporting that there is continued use and several modifications of this technique, such as performing it through a small thoracotomy without the use of the cardiopulmonary bypass.Abbreviations: AAC, Apico Aortic Conduit; AS, aortic stenosis; AVR, aortic valve replacement; BSA, body surface area; CABG, coronary artery bypass grafting surgery; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; CPB, cardiopulmonary bypass; DHCA, deep hypothermic circulatory arrest; FEM-FEM, femoro-femoral; ITA, internal thoracic artery; LITA, left internal thoracic artery; LVH, left ventricular hypertrophy; LVOT, left ventricle outflow tract; NYHA, New York Heart Association; MDCT, multidetector-computerized tomography; MVR, mitral valve replacement; OPCAB, off pump coronary artery bypass; PH, pulmonary hypertension; RITA, right internal thoracic artery; TEE, transesophageal echocardiography; TAVI, transcatheter aortic valve implantation     

Percutaneous coronary intervention of a saphenous vein graft ostial stenosis in a patient with Bentall procedure

Composite graft replacement of the aortic root and coronary reimplantation with or without coronary artery bypass surgery is the standard treatment for a variety of aortic root pathologies. Previously, percutaneous coronary intervention of either reimplanted coronary arteries or left/right coronary artery through cabrol graft has been described in post-Bentall patients. We describe percutaneous coronary intervention of a saphenous vein graft ostial stenosis in a patient with previous Bentall procedure and a vein graft to right coronary artery, which was complex and challenging.     

Should a Regurgitant Mitral Valve Be Replaced Simultaneously with a Stenotic Aortic Valve?

Mitral valve regurgitation frequently accompanies aortic valve stenosis. It has been suggested that mitral regurgitation improves after aortic valve replacement alone and that the mitral valve need not be replaced simultaneously Furthermore, mitral regurgitation associated with coronary artery disease, particularly in patients with poor left ventricular function, shows immediate improvement after coronary artery bypass grafting. We studied 60 consecutive patients with aortic stenosis and mitral regurgitation to determine the degree of improvement in mitral regurgitation after aortic valve replacement alone versus aortic valve replacement combined with coronary artery bypass grafting. Thirty-six of the patients had normal coronary arteries (Group 1); the other 24 had symptomatic coronary artery disease requiring bypass surgery (Group 2). Echocardiography was performed preoperatively, 1 week postoperatively, and at follow-up. In Group 1, left ventricular ejection fraction did not improve early or at 2.5 months postoperatively, but mitral regurgitation improved gradually during follow-up. In Group 2, mitral regurgitation showed improvement 1 week postoperatively (p < 0.001), and left ventricular ejection fraction was improved at 2.5 months. We conclude that patients with aortic valve stenosis and mild-to-severe mitral regurgitation, without echocardiographic signs of chordal or papillary muscle rupture and without coronary artery disease, should undergo aortic valve replacement alone. The mitral regurgitation will remain the same or improve. For patients with coexisting coronary artery disease, simultaneous aortic valve replacement and coronary artery bypass grafting are imperative; however, the mitral valve again requires no intervention, since mitral regurgitation improves significantly after the other 2 procedures.     

Left Main Coronary Artery Obstruction by Dislodged Native-Valve Calculus after Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement can be an effective, reliable treatment for severe aortic stenosis in surgically high-risk or ineligible patients. However, various sequelae like coronary artery obstruction can occur, not only in the long term, but also immediately after the procedure. We present the case of a 78-year-old woman whose left main coronary artery became obstructed with calculus 2 hours after the transfemoral implantation of an Edwards Sapien XT aortic valve. Despite percutaneous coronary intervention in that artery, the patient died. This case reminds us that early recognition of acute coronary obstruction and prompt intervention are crucial in patients with aortic stenosis who have undergone transcatheter aortic valve replacement.     

Severe syphilitic aortic regurgitation with bilateral critical coronary ostial stenosis

A forty-year-old male with syphilitic severe aortic regurgitation and critical bilateral coronary ostial stenosis, proved by cardiac catheterization and angiocardiography, is presented. He underwent successful aortic valve replacement and coronary artery bypass grafting with gratifying results.     

大动脉炎累及冠状动脉的特点和外科治疗

目的:探讨大动脉炎累及冠状动脉的特点和外科治疗.方法:共手术治疗6例冠状动脉开口狭窄或闭塞的患者,其中5例行冠状动脉旁路移植术,1例直接扩大冠状动脉开口;同期行升主动脉-腹主动脉人工血管转流术1例,Bentall主动脉根部替换术2例,Cabrol主动脉根部替换术和二尖瓣替换术1例.结果:无手术死亡.发生围术期心肌梗死和低心排综合征1例.结论:大动脉炎累及冠状动脉的同时,常合并主动脉及其分支的狭窄,也常同时合并升主动脉壁增厚、扩张和(或)主动脉瓣关闭不全等,明显增加了同期手术的难度.由于锁骨下动脉常受累,乳内动脉不适于作为旁路移植材料.