Postoperative Coronary Artery Spasm Complicating Aortic Valve Replacement: Implications for Identification and Treatment

Intraoperative right coronary artery obstruction due to aortic root prosthesis mismatch after aortic valve replacement-A case report

Iatrogenic intraoperative coronary artery ostial occlusion is quite rare and a dangerous complication of aortic valve replacement. Intraoperative vigilance and prompt intervention are required to manage this fatal complication. A case report of a 48-year-old female with normal coronaries who underwent aortic valve replacement and had right ventricle distension is described here. It seemed that the cause which led to right coronary ostial obstruction was due to prosthesis aortic root mismatch and it required bypass with a vein graft. Computed tomographic angiography of aortic root showed abutting of right coronary ostium by the aortic valve prosthesis.

Postoperative coronary artery spasm after mitral valve replacement

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Coronary artery spasm occurred after mitral valve replacement in a patient with normal coronary arteries.

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The patient had ST changes and inferior wall hypokinesia.

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The diagnosis was established by urgent postoperative coronary angiography.

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The spasm responded to the intracoronary injection of nitrates.

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The remaining postoperative course was uneventful and the left ventricular function returned to normal.

Introduction

Postoperative coronary artery spasm is an infrequent life-threatening event after cardiac surgery which can occur without an underlying coronary disease

Presentation of case

We report a documented case of a 67-year-old man with normal coronary arteries submitted to mitral valve replacement. Immediately after surgery he had a ST elevation in the inferior leads, and an inferior wall hypokinesia at the trans-oesophageal echo. A coronary angiography demonstrated a focal spasm in the right coronary artery which was successfully treated by intracoronary injection of nitrates. The following postoperative course was uneventful and the left ventricular function returned to normal.

Discussion

A coronary artery spasm should be suspected whenever a postoperative infarction occurs after valvular surgery especially in absence of associated coronary artery disease. In this cases postoperative coronary angiography allows both the diagnosis and the treatment.

Conclusion

This case-report summarizes the findings of this rare and potentially life-threatening cause of early postoperative ischemia and highlights the role of early coronary angiography in the cases of suspected myocardial infarction after cardiac surgery

Cardiopulmonary bypass weaning difficulty due to anomalous origin of coronary artery -A case report-

We report a case of hemodynamic instability after aortic valve replacement, due to the anomalous origin of the right coronary artery. During the cardiopulmonary bypass weaning process, hemodynamic instability occurred. The cause was not identified at first, and compression of the anomalous right coronary artery was thought to be the culprit, thereafter.

Coronary ostia obstruction after replacement of aortic valve prosthesis

Aortic valve replacement (AVR) is the gold standard for the treatment of severe symptomatic aortic stenosis. Complications directly related to surgical procedure are relatively infrequent. Coronary ostial stenosis is, generally, referred as late complication. Anecdotal reports concern coronary ostial stenosis as acute complication. A unique fatal case of intraoperative, bilateral coronary ostial obstruction by prosthetic valve leading to an extensive myocardial infarction is reported. Surgeons must have a high level of vigilance regarding the occurrence of acute myocardial ischemia and sudden death soon after AVR.

Recurrent ventricular fibrillation due to coronary artery spasm immediately after ascending aorta replacement

Coronary artery spasm (CAS) is a dangerous complication during cardiac surgery, causing arduous weaning of extracorporeal circulation (ECC) and myocardial tissue loss with consequent left and right ventricular dysfunctions. We describe the case of a 67-year-old man with hypertension and smoking habit, with ECG evidence of lateral myocardial ischemia without symptoms. On this basis, he was investigated with scintigraphy, which confirmed an anterior-lateral area of reversible ischemia and, subsequently, with angiography, which revealed just mild lesion (50%) of diagonal ramus associated with ascending aorta aneurysm: no sign of CAS was detected. Left ventricular function was normal, with mild hypokinesia of the apical segments and trivial aortic regurgitation. The patient underwent ascending aorta replacement with arduous ECC weaning due to CAS: exclusively, the use of intravenous administration of diltiazem led to the solution of this complication. Even if medical therapy is generally efficacious for this complication, the diagnosis is very complicated when it appears in the operating room immediately after cardiac surgery because of the lack of any useful device. The difficulty of diagnosis in the operating room might compromise patient outcome. In our opinion, when ECC weaning is complicated by several episodes of malignant tachyarrhythmia and there is the suspicion of underlying ischemic cause without other obvious causes, CAS must be considered and empirical therapy with calcium channel blockers should be used.

Early impairment of left ventricular long-axis systolic function demonstrated by reduced atrioventricular plane displacement in patients with Marfan syndrome

AIMS

Marfan syndrome (MFS) is a connective tissue disorder caused by mutations in the fibrillin-1 (FBN1) gene. It has been observed that FBN1 deficient mice have reduced left ventricular (LV) systolic function which is correlated to increased transforming growth factor-beta activity. This study aimed to ascertain LV functional abnormalities in MFS patients using M-mode and tissue Doppler imaging (TDI).

METHODS AND RESULTS

In 66 (15-58 years) MFS patients and 61 normal controls, ejection fraction (EF) was evaluated by Simpson's biplane method. Atrioventricular plane displacement (AVPD) obtained from five mitral annular regions was also assessed using M-mode and TDI techniques. To overcome limitations associated with conventional M-mode echocardiography, anatomical and colour anatomical M-mode were also utilized. Ejection fraction was significantly reduced in MFS patients when compared to controls (66.3 +/- 0.74 vs. 71.9 +/- 0.56, P < 0.001), although it was within the normal range. M-mode and TDI AVPD measurements obtained from lateral, septal, inferior, anterior and posterior mitral annular regions were also significantly reduced in MFS patients in comparison to controls (P <0.001, for all measurements).

CONCLUSION

Left ventricular long-axis systolic function is significantly reduced in MFS patients. This data suggests that LV function should be monitored in MFS and appropriate treatment applied if necessary.