Lessons learnt from this unusual complication

A 16-years-old male with prior diagnosis of situs inversus totalis and pulmonary atresia with interventricular communication underwent percutaneous pulmonary valve implantation 3 months after successful RVOT stenting following a negative balloon sizing test. Once finished the procedure, after consciousness recovery in the intensive care unit, the patient developed oppressive chest pain with very subtle electrocardiographic changes over his basal right bundle branch block. An urgent coronary angiography showed a severe stenosis in the proximal right coronary artery with TIMI 2 distal flow. Intravascular ultrasound imaging confirmed extrinsic compression. A 4 × 21 mm drug-eluting stent was successfully implanted relieving symptoms immediately. TIMI 3 flow was restored and good apposition and expansion were confirmed with intravascular ultrasound. A carefully review of the procedure showed that the pitfall responsible for this complication was the oversizing of the valve with respect to the size of the balloon used for the sizing test.

Acute coronary syndrome caused by extrinsic coronary compression from an aortic root abscess in a patient with mechanical aortic valve endocarditis: a case report and literature review

Background 

Extrinsic coronary compression is an extremely rare complication of aortic root abscess formation and can manifest as an acute coronary syndrome in infective endocarditis. Optimal management strategies are unknown and therefore illustrative case reports may be informative.

Case summary 

We describe a 63-year-old man with a background history of a mechanical aortic valve who developed sepsis due to Escherichia coli bacteraemia from a presumed urinary source. He suddenly deteriorated with cardiogenic shock and anterior ST-segment elevation myocardial infarction on Day 16 and received emergency percutaneous coronary intervention for severe stenoses of left anterior descending and diagonal arteries. A transoesophageal echocardiogram 2 days later demonstrated a large aortic root abscess. He was transferred for emergency surgery which revealed a large aortic abscess surrounding the left main stem confirming extrinsic coronary compression. He received a redo tissue aortic valve replacement and repair of his abscess cavity.

Discussion 

We describe a case where percutaneous coronary intervention and emergency surgery was used to treat extrinsic compression from an aortic root abscess; a complication that is associated with a high mortality. This is also a rare case of E. coli causing prosthetic valve endocarditis. We also explore the findings of 11 previous cases of extrinsic coronary compression from aortic root abscess.

Large sub-mitral aneurysm compressing the left circumflex coronary artery presenting with atypical chest pain - Rare presentation

Sub-mitral aneurysm (SMA) is a rare cardiac malformation commonly reported in young adults of African ancestry. SMA is considered a congenital disease caused by developmental defect due to weakness at the atrioventricular junction near the posterior mitral annulus. In the past two decades, a considerable number of cases regarding this rare disease have been reported in Asians, highlighting the importance of considering SMA in differential diagnosis of young patients presenting with mitral regurgitation and chest pain. Herein, we report the case of a young male with atypical chest pain with compression of left circumflex coronary artery by a large SMA. <Learning objective: Sub-mitral aneurysm is a rare cardiac malformation, caused by developmental defect due to weakness at the atrioventricular junction near the posterior mitral annulus. Patients may be entirely asymptomatic, or they can present with mitral regurgitation with or without left ventricular dysfunction, heart failure, systemic thromboembolism, ventricular wall rupture causing tamponade, myocardial ischemia due to compression of coronary arteries, ventricular arrhythmias, or sometimes sudden cardiac death. Strong suspicion and early diagnosis followed by surgery can prevent sudden cardiac death.>.

Cardiac CT to assess the risk of coronary compression in patients evaluated for percutaneous pulmonary valve implantation

BACKGROUND

Coronary compression (CC) is a life threatening complication that can occur during percutaneous pulmonary valve implantation (PPVI). We describe our experience using cardiac CT prior to PPVI to identify patients at high CC-risk due to a close relationship between the coronary arteries and pulmonary trunk (PT).

METHODS

A retrospective evaluation of candidates for PPVI who underwent CT prior to the procedure was done. Measurements of PT were performed using double oblique reconstructed images, with special attention to the stenotic tract of the PT. The analysis of coronary arteries included detection of anomalies of origin and course and assessment of their relationship with the PT, measuring the minimum distance between the coronary artery and the intended site of the future percutaneous valve implantation.

RESULTS

CT analysis was performed for 52 patients. Thirty patients underwent PPVI after CT and 22 didn't. In 6/22 cases the reason not to receive a PPVI was high CC-risk detected at CT. In 6 other patients CT detected an intermediate CC-risk but the test balloon performed during angiography prior to valve placement was safe and the patients successfully underwent the procedure. None of the patients deemed as no CC-risk at CT had CC during PPVI.

CONCLUSION

CT can detect patients with high and intermediate CC-risk and therefore may identify which patients are unlikely to undergo successful PPVI and those who need a careful analysis with balloon testing. CT can also rule out CC-risk identifying those patients in which balloon inflation testing could be omitted.

Preprocedural Risk Assessment Prior to PPVI with CMR and Cardiac CT

Percutaneous pulmonary valve intervention (PPVI) is a less invasive and less costly approach to pulmonary valve replacement compared with the surgical alternative. Potential complications of PPVI include coronary compression and pulmonary arterial injury/rupture. The purpose of this study was to characterize the morphological risk factors for PPVI complication with cardiac MRI and cardiac CTA. A retrospective review of 88 PPVI procedures was performed. 44 patients had preprocedural cardiac MRIs or CTAs available for review. Multiple morphological variables on cardiac MRI and CTA were compared with known PPVI outcome and used to investigate associations of variables in determining coronary compression or right ventricular-pulmonary arterial conduit injury. The most significant risk factor for coronary artery compression was the proximity of the coronary arteries to the conduit. In all patients with coronary compression during PPVI, the coronary artery touched the conduit on the preprocedural CTA/MRI, whilst in patients without coronary compression the mean distance between the coronary artery and the conduit was 4.9 mm (range of 0.8-20 mm). Multivariable regression analysis demonstrated that exuberant conduit calcification was the most important variable for determining conduit injury. Position of the coronary artery directly contacting the conduit without any intervening fat may predict coronary artery compression during PPVI. Exuberant conduit calcification increases the risk of PPVI-associated conduit injury. Close attention to these factors is recommended prior to intervention in patients with pulmonary valve dysfunction.

Three dimensional rotational angiography for assessment of coronary arteries during melody valve implantation: introducing a technique that may improve outcomes

Background

Adverse events from Melody valve implantation may be catastrophic. To date a role for three dimensional rotational angiography of the aortic root (3DRAA) during Melody valve implantation has not been established.

Objectives

To describe the role of 3DRAA in the assessment of Melody valve candidacy and to demonstrate that it may improve outcomes.

Methods

All patients who underwent cardiac catheterisation for Melody valve implantation and 3DRAA between August 2013 and February 2015 were reviewed.

Results

31 patients had 3DRAA with balloon sizing. Ten were deemed not Melody candidates (5 coronary compression, 2 aortic root distortion with cusp flattening, 2 RVOT was too large, and 1 had complex branch stenosis and a short landing zone). Of the 21 patients who were Melody candidates, 12 had conduits, 6 prosthetic valves and 3 native RVOTs. In patients with conduits, the technique of stenting the conduit prior to dilation was used after measuring the distance between the conduit and the coronary arteries on 3DRAA. In the Melody patients, we had 100% procedural success and no serious adverse events (coronary compression, tears, stent fracture or endocarditis).

Conclusion

As a tool for case selection, 3DRAA may facilitate higher procedural success and decreased risk of serious adverse events. Furthermore, 3D rotational angiography allows stenting of the conduit prior to dilation, which may prevent tears and possibly endocarditis.

Acute coronary syndrome due to coronary artery compression by a metastatic cardiac tumor

A 60-year-old female without coronary risk factors was admitted to the hospital with ST-elevation acute coronary syndrome (ACS). She had previously suffered breast cancer and received radical mastectomy followed by chemotherapy and radiation. Emergent coronary angiography showed an occlusion of the proximal left anterior descending coronary artery (LAD) and coronary angioplasty was performed. Coronary computed tomography (CT) angiography (CTA) disclosed a tumor invading the left ventricular anterior wall and surrounding the coronary artery. Myocardial single-photon-emission CT (SPECT) using 123I-BMIPP showed a defect in the same portion. A fusion image of the CTA and the SPECT delineated a tumor surrounding the coronary artery. She finally died two months later from a terminal condition. Autopsy demonstrated a tumor involving the left ventricular anterior wall and surrounding the LAD. Pathology of the affected LAD showed only fibrous plaque without vulnerable plaque, thrombus, or tumor invasion to the coronary wall. Thus, compression of the coronary artery by the metastatic tumor was the most likely mechanism of ACS.