Author + information
- Received March 6, 2015
- Revision received March 19, 2015
- Accepted March 26, 2015
- Published online September 1, 2015.
- Sandeep Basavarajaiah, MD∗ ( and )
- Anik Appaji, MD
- ↵∗Reprint requests and correspondence:
Dr. Sandeep Basavarajaiah, Heart of England NHS Trust, Rectory Road, Sutton Coldfield, Birmingham, B75 5RR United Kingdom.
A 65-year-old woman presented with symptoms of crescendo angina 7 months after bioprosthetic aortic valve replacement (AVR) for stenosis of a previously placed prosthetic valve. She was initially reassured by her general physician after an echocardiogram that demonstrated a normally functioning prosthetic valve. In addition, a coronary angiogram before surgery had demonstrated normal arteries (Figure 1). Due to her classic symptoms, we repeated the angiography, which exhibited tight ostial stenosis of the left main stem (LMS) (Figure 2). She subsequently underwent successful angioplasty with deployment of 1 drug-eluting stent (4.5 × 14-mm everolimus-eluting stent) (Figures 3A, 3B, and 4). The surgeon confirmed the cannulation of LMS during aortic valve surgery to induce cardioplegia.
Iatrogenic ostial LMS stenosis is a rare but life-threatening complication after valve surgery. It is attributed to a localized hyperplastic reaction secondary to antegrade cannulation of the coronary ostia to induce cardioplegia. Cannulation may lead to microinjuries due to perfusion pressure of cardioplegic fluid and overdilation of the vessel by the tip of the catheter (1–3). In our case, because the LMS was at an acute angle from the aortic sinus, the cannulation might have caused a greater degree of intimal injury. One of the main challenges is the diagnosis because chest pain post-AVR may be overlooked, especially in the absence of valve dysfunction and if the preoperative angiogram was normal. The condition is rapidly progressive, and without treatment, there is a risk of sudden death. Our patient was experiencing chest pain on minimal exertion and sometimes even at rest.
Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received March 6, 2015.
- Revision received March 19, 2015.
- Accepted March 26, 2015.
- American College of Cardiology Foundation
- Doenst T.