Author + information
- Received January 23, 2017
- Accepted January 26, 2017
- Published online April 3, 2017.
- aDepartment of Cardiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- bDepartment of Radiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- ↵∗Address for correspondence:
Dr. Biao Xu, Nanjing University Medical School, 321 Zhongshan Road, Nanjing, Jiangsu 210008, China.
A 72-year-old woman was admitted because of progressive 9-year chest tightness. Nine years ago, she underwent mitral valve replacement using a Hancock II porcine mitral valve bioprosthesis (size 27) (Medtronic, Minneapolis, Minnesota) for posterior mitral valve prolapse. Pre-operative coronary angiogram showed anomalous origin of left circumflex artery (LCx) without stenosis (Figure 1A, Online Video 1). Post-operative echocardiography showed a left ventricular ejection fraction of 51%.
However, recent echocardiography showed a decreased left ventricular ejection fraction of 36% and segmentally weakened motion of the inferior and lateral wall. Single-photon emission computed tomography showed myocardial ischemia of the inferior and lateral wall. Diagnostic coronary angiogram identified a severe proximal LCx stenosis with distal slow flow (Figure 1B, Online Video 2). Both the left anterior descending and right coronary arteries seemed normal. Then percutaneous coronary intervention was performed with a 6F catheter Amplatz L 1.0 guide catheter. After pre-dilation of stenosis with a 2.5 × 15 mm balloon, intravascular ultrasound catheter detected a marked reduction of vessel lumen without significant atherosclerotic plaques (Figure 2A and 2B, Online Video 3). Then we delivered a 3.5 × 36 mm drug-eluting stent to proximal LCx. Final angiogram (Figure 1C, Online Video 4) and intravascular ultrasound (Figure 2C, Online Video 5) showed a good result. Six days later, computed tomography coronary angiography showed that LCx ectopically originated from the right sinus of Valsalva, coursed posteriorly to the aorta, then traveled tightly around the mitral annulus (Figure 3). The patient performed well after discharge until now.
This is a rare case of anomalous original LCx stenosis after mitral valve replacement. We speculate that compression of the mitral valve bioprosthesis suture ring against surrounding tissues of the mitral annulus might cause the LCx stenosis. Long-term outcome of artificial mitral valve replacement in such patients should be followed up.
For supplemental videos and their legends, please see the online version of this article.
All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received January 23, 2017.
- Accepted January 26, 2017.
- 2017 American College of Cardiology Foundation