Acute coronary artery obstruction after aortic valve replacement surgery and role of transesophageal echocardiography

Abstract

Acute coronary artery obstruction is a rare but potentially fatal complication of aortic valve replacement (AVR) surgery [1,2]. This adverse event can be induced by sudden coronary spasm, embolization of calcium plaque on the coronary arterial walls or aortic root, or intraoperative iatrogenic events [3].We present the near-fatal case of a patient who experienced a significant left main coronary ostial obstruction immediately after weaning from cardiopulmonary bypass (CPB). In the case presented here, early detection of regional wall motion abnormalities (RWMAs) in the left coronary arterial territory using intraoperative transesophageal echocardiography (TEE) prevented delayed diagnosis and poor outcome. CASE REPoRTA 60-year-old woman was referred to our hospital with dys- Acute coronary artery obstruction is a rare but fatal complication of surgical aortic valve replacement (AVR). Sudden coronary spasm, embolization of calcium plaque, and surgical factors can induce acute coronary syndrome after AVR. Here, we report a case of left main coronary ostial obstruction that occurred immediately after weaning from cardiopulmonary bypass. This case highlights the importance of coronary ostial flow patency and assessment of regional wall motion abnormalities with intraoperative transesophageal echocardiography in AVR.

Antiphospholipid syndrome and valvular heart disease, a complex scenario of thrombotic events, a case report

“…Even so, early surgical aortic-valve replacement should be considered in these patients as a significantly lower risk of operative mortality is found than conservative management among asymptomatic patients with very severe aortic stenosis [10]. When valve replacement is necessary the morbidity and mortality for these patients are higher (50 and 22%) compared to the mortality in non-APS patients 2% [1,8,9]. This may be accounted for by several factors including, renal insufficiency, anemia, and thromboembolism.…”

“…This may be accounted for by several factors including, renal insufficiency, anemia, and thromboembolism. Perioperative thrombosis caused by antiphospholipid antibodies during the procedure can be catastrophic and should always be considered and prevented [5,9,11].…”

“…When it occurs, valve replacement surgery is needed in up to 6% of these patients [ 3 , 5 , 7 ]. In asymptomatic patients with AS, surgery is recommended when the left ventricular ejection fraction is less than 50% or when exercise stress tests are abnormal and should be considered when the mean pressure gradient is beyond 60 mmHg, the aortic jet velocity is above 5 m/s, there is evidence of a left ventricular hypertrophy, elevated B-type natriuretic peptide and reduced global left ventricular strain in low-risk patients [ 8 , 9 ]. Nonetheless, our patient had APS that made her situation even more complicated, not only because of the increased surgical risk but because of her perioperative management.…”

“…There are few cases reports in the literature of this dreadful condition. Obstruction from the aortotomy sutures, post-traumatic thrombosis due to the aortic retractor, embolism from debris, and surgical glues have been found as the cause of coronary obstruction [ 7 , 9 ]. Nonetheless, after an extensive search in the literature, we haven’t found a report of this phenomenon in the setting of an APS patient with an aortic valve replacement surgery.…”

Unroofing of Left Coronary Artery in a Patient with Aortic Valve Replacement

“…It may be as a result of damage secondary to cardioplegia delivery system, debris from decalcification of the heavily calcified aortic valve or due to sewing ring of the prosthetic valve completely or partially obstructing the left or right coronary ostium. Irrespective of the cause this complication is fatal and requires recognition and correction by re-implantation of the valve or performing Coronary artery bypass (CABG) in the relevant coronary artery or percutaneous intervention and stenting as in one of the reported case where patient developed coronary compromise detected as wall motion abnormality on TOE and confirmed on angiography [6]. It is also important to note that because of various etiologies of ostial obstructions even transcatheter aortic valve replacement (TAVI) can lead to coronary artery obstruction that may be fatal [7].…”