Abstract
Iatrogenic coronary ostial stenosis following aortic valve replacement (AVR) occurs in up to 3.4% of cases and usually presents within the first 6 months following surgery. We present the case of an 85 year old man who developed an acute coronary syndrome 2 months following AVR. Coronary angiography revealed a severe de novo lesion in the left main stem, which, on optical coherence tomography, was shown to be due to severe intimal hyperplasia. The most likely underlying mechanism is vessel wall trauma caused by the rigid tip cannula used for administration of cardioplegia solution. Surgeons should be aware of this possibility when administering this solution via the antegrade approach.
1
Case
An 85 year old male underwent coronary angiography in September 2011 to delineate coronary anatomy prior to aortic valve replacement (AVR) for severe symptomatic aortic stenosis. This revealed a severe lesion in the proximal right coronary artery (RCA) but no significant disease elsewhere, including the left main stem (LMS) ( Fig. 1 ). He underwent successful tissue AVR and a single saphenous vein graft (SVG) to the RCA in December 2011. Cardioplegic solution was administered antegradely into the LMS and RCA using a rigid tip cannula ( Fig. 2 ), connected to an infusion pump.
The patient was readmitted in February 2012 with typical, cardiac-sounding chest pain and a raised serum cardiac troponin. Repeat coronary angiography revealed a patent SVG to the RCA, but there was a severe lesion in the mid/distal LMS which was thought to be the culprit lesion ( Fig. 3 ). Further assessment of the LMS with Fourier-domain optical coherence tomography (OCT) (C7-XR system, LightLab Imaging Inc., Westford, Massachusetts) revealed marked intimal hyperplasia at the site of the lesion ( Fig. 4 ). The lesion was successfully stented with a 4 mm × 16 mm Promus Element drug-eluting stent ( Fig. 5 ) and routine check coronary angiography 6 months later revealed complete coverage of stent struts with neointimal tissue ( Fig. 6 ). The recommended dual antiplatelet regimen in his case was Ticagrelor for one year and Aspirin for life.
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