Critical Left Main Coronary Stenosis After Sutureless Aortic Valve Replacement

J INVASIVE CARDIOL 2020;32(6):E170-E171.

Key words: left main coronary artery stenosis, percutaneous coronary intervention, sutureless aortic valve replacement

A 65-year-old woman presented with severe chest pain and acute pulmonary edema 2 months after triple valve operation. Preoperative coronary angiogram showed normal left main coronary artery (LMCA) and left anterior descending (LAD), a calcified 90% stenosis over the mid right coronary artery (RCA), and diffuse disease over a non-dominant left circumflex (LCX). A triple-valve operation was performed with a saphenous vein graft to distal RCA under direct coronary cardioplegia, using a size-S Perceval sutureless aortic bioprosthesis (Sorin Group Canada), a mitral bioprosthesis, and a tricuspid down-sized annuloplasty ring. 

She rapidly deteriorated into cardiogenic shock. Electrocardiogram showed LMCA ischemia pattern. Echocardiography showed globally impaired left ventricular function, with ejection fraction of only 25%. Coronary angiogram revealed critical LMCA stenosis with blocked venous graft. Heart team meeting recommended percutaneous coronary intervention (PCI) under venoarterial extracorporeal membrane oxygenation (VA-ECMO) support due to ultra-high reoperative risk.

PCI was performed via right radial approach. The LMCA was engaged with difficulty due to distorted aortic root anatomy after Perceval valve implantation. It was eventually engaged through the stent cells with a 6 Fr Judkins left 3.5 guiding catheter (Cordis Corporation). Cross-sectional intravascular ultrasound of the LMCA (Figure 1) showed increased plaque load suggestive of accelerated atherosclerosis with evidence of prior coronary dissection. A 4.0 x 11 mm drug-eluting stent was used to cover the LMCA lesion with small protrusion beyond the ostium. In view of the blocked SVG, PCI to native RCA was performed in the same session with lesion preparation by rotational atherectomy. Final angiographic results were satisfactory (Figure 2). The patient was discharged 2 weeks later and remained free of chest pain.

The incidence of coronary ostial stenosis following aortic valve replacement is low (<3%). A few hypotheses have been postulated to account for this complication. First, direct coronary cardioplegic fluid could lead to microinjury and local hyperplastic reaction of coronary arteries. Second, direct trauma or overdilation of the vessel by the coronary catheter for cardioplegia might result in LMCA dissection or hematoma formation. Third, intimal thickening and fibrosis of the implanted prosthesis near the aortic root have been reported to cause turbulent flow, leading to coronary obstruction. The cage of the sutureless valve could be responsible for excessive stress of the cannula, resulting in the early ostial lesion. Our case illustrates the feasibility of high-risk PCI to salvage LMCA stenosis, possibly caused by coronary injury during direct coronary cardioplegia for a recent triple-valve operation.

From the Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People’s Republic of China.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein. 

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted October 8, 2019.

Address for correspondence: Dr Chi Wai Kin, Division of Cardiology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, 9/F Clinical Science Building, Prince of Wales Hospital, 30-32 NganShing Street, Shatin, NT, Hong Kong SAR, China. Email: chiwaikin@gmail.com