Abstract
The incidence of calcified debris coronary embolism after aortic valve replacement (AVR) with a bioprosthesis is a rare but potentially life-threatening condition. We sought to describe a case of immediate postoperative left main coronary artery embolism, resulting to severe acute coronary syndrome and cardiogenic shock, after aortic valve surgery due to severe aortic valve stenosis, with the use of bioprosthesis. Complex interventional procedures and possible diagnostic challenges are being described.
1
Introduction
Intraoperative embolism of calcified fabric to the left main coronary artery (LMCA) after aortic valve replacement (AVR) is an infrequent but potentially fatal complication . The incidence of this event has been reported to range between 0.3% and 5%, both after mechanical and bioprosthetic valve use . In the present report, a unique case of rapid postoperative LMCA calcium embolisation is described, after AVR with a Saint Jude EPIC bioprosthetic valve, in a patient with severe aortic valve stenosis. Diagnostic approach and complex interventional procedures are being thoroughly discussed.
2
Case presentation
A 69-year-old male patient was admitted for regular preoperative evaluation due to severe aortic valve stenosis. Prior medical history revealed a history of hypertension, hypercholesterolemia, and hypertriglyceridemia. Transthoracic echocardiography revealed severe aortic stenosis with extensive calcification of the leaflet and the aortic ring. The aortic valve area was estimated at 0.6 cm 2 with a mean pressure gradient of 50 mmHg. Preoperative coronary angiography showed one-vessel disease with a 70% lesion in the distal segment of the left anterior descending (LAD) coronary artery ( Fig. 1 A ). The patient was subjected to AVR surgery through a midline sternotomy and a bioprosthetic valve, Saint Jude Medical EPIC 21 mm, was inserted. Myocardial protection was achieved by antegrade cold blood cardioplegia. No bypass graft was used for the LAD lesion as it was located very distally and a diffused diseased segment followed afterwards.
After sternal closure as the patient had just been transferred to the intensive care unit, sudden circulatory collapse occurred with rhythm disturbances and severe hypotension. An emergency transesophageal echocardiogram showed a regionally disturbed left ventricle function with apical septal and apical inferior wall segment akinesia. The bioprosthesis was regularly sited in an annular position, with typical leaflet movement and no paravalvular insufficiency.
The subsequent urgent coronary angiography showed a severe obstruction of distal LMCA with a material of unknown origin which was expanding in the LAD ostium just after the origin of LAD and a large intermediate artery ( Fig. 2 ). The unknown fabric fluoroscopically resembled a calcified debris or a thrombotic fragment. In view of the patient’s symptoms and the distinct angiographic visualisation, a thrombus aspiration catheter was used (Export XT Aspiration Catheter, Medtronic, Minneapolis, MN, USA), but the material could not be removed. The initial speculation of a calcified debris was increasingly becoming stronger. Initially, the lesion was crossed with a Universal Balance Middleweight 0.0014-in. (Abbott Vascular, Abbott Park, IL, USA) guidewire, while a floppy guidewire (Galeo HF 0.014) was used for intermediate coronary artery (ICA) branch. A 2.5×15-mm Quantum Maverick Balloon Catheter (Boston Scientific, Natick, MA, USA) was relatively easily advanced through the severe lesion and predilated with 12 atm ( Fig. 3A ). Full balloon expansion was achieved and the immediate result showed residual material existence, with no apparent dissection. After that, a 3.5×23-mm Promus stent (Boston Scientific) was successfully deployed at 14 atm in order to cover the lesion from distal LM to proximal LAD covering this way the LAD and ICA bifurcation ( Fig. 3B ). The jailed wire was removed and a new wire was advanced trough stent struts in order to finalise the procedure with kissing balloon angioplasty between LAD and LCx ( Fig. 3 C). The angiographic result was optimal, while the patient was gradually improved ( Fig. 3D ). A TnT value of 23.6 almost 6 h after circulatory collapse with a value of 0.790 immediately postoperatively confirmed postoperative myocardial infarction. On the fourth day, TEE showed a mild LV dysfunction with a normal functioning bioprosthetic valve. The patient was released from mechanical ventilation support on the third day after the event, but he needed a few days of hospitalisation due to renal function impairment. He was prescribed with dual antiplatelet therapy (aspirin and clopidogrel) for 6 months with an advice to undergo a control coronary angiography in 6 months.
2
Case presentation
A 69-year-old male patient was admitted for regular preoperative evaluation due to severe aortic valve stenosis. Prior medical history revealed a history of hypertension, hypercholesterolemia, and hypertriglyceridemia. Transthoracic echocardiography revealed severe aortic stenosis with extensive calcification of the leaflet and the aortic ring. The aortic valve area was estimated at 0.6 cm 2 with a mean pressure gradient of 50 mmHg. Preoperative coronary angiography showed one-vessel disease with a 70% lesion in the distal segment of the left anterior descending (LAD) coronary artery ( Fig. 1 A ). The patient was subjected to AVR surgery through a midline sternotomy and a bioprosthetic valve, Saint Jude Medical EPIC 21 mm, was inserted. Myocardial protection was achieved by antegrade cold blood cardioplegia. No bypass graft was used for the LAD lesion as it was located very distally and a diffused diseased segment followed afterwards.
