Ann Thorac Surg 2004;77:1854-1856
© 2004 The Society of Thoracic Surgeons
How to do it
Coronary ostial enlargement to prevent stenosis after prosthetic aortic valve replacement
Francesco Santini, MDa*,
Samuele Pentiricci, MDa,
Antonio Messina, MDa,
Alessandro Mazzucco, MDa
a Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
Accepted for publication July 25, 2003.
* Address reprint requests to Dr Santini, Division of Cardiac Surgery, Piazzale Stefani 1, 37126 Verona, Italy.
e-mail: fsant{at}yahoo.com
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Abstract
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Iatrogenic left and/or right coronary artery ostial stenosis after aortic valve replacement is a rare but life-threatening complication. Although usually related to trauma to the ostium/a during cannulation for administration of cardioplegia, it may be rarely due to direct obstruction by the prosthetic annular ring or stent. We report herein an alternative technique to manage this complication when due to the latter event, successfully utilized at our institution over the last eleven years.
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Introduction
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Iatrogenic left and/or right coronary artery ostial stenosis after aortic valve replacement is a rare but life-threatening complication [1–4]. More often its clinical onset occurs months after the procedure and is thought to be linked to trauma to the coronary endothelium related to cannulation of the ostia during direct administration of cardioplegia for myocardial protection [1, 3–5]. Rarely it may be due to a variable degree of direct obstruction of the coronary ostia by the prosthetic annular ring or stent. This may be a consequence of a poor valve-to-annular size matching but can also depend on an unfavorable anatomical substrate with a very low coronary ostia take-off, quite proximal to the aortic annulus.
Surgeons usually realize this complication at the end of the procedure after the aortic prosthetic device has been sown. Beside removal of the valve, its management may require enlargement of the aortic annulus, re-replacement with a smaller device, or both procedures. This strategy, however, may result in a very long aortic cross-clamp time and, as a consequence, a variable degree of myocardial dysfunction with potentially dreadful consequences.
We report herein an alternative technique to manage this complication successfully utilized at our institution with three patients over the last eleven years.
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Technique
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Out of more than 1800 aortic valve replacements performed at the Division of Cardiac Surgery of the University of Verona since 1992, three patients (< 0.2%), 2 male and 1 female, with a mean age of 66.6 years, operated upon for aortic stenosis, showed the abovementioned intraoperative complication.
In all cases, after the mechanical prosthesis was tied down in its final position, the coronary ostia (both in two cases; left main alone in one) appeared partially occluded by the device (Fig 1A).
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Fig 1. (A) Diagram showing the prosthetic device partially occluding the left main coronary ostium. (B) The left coronary ostium is opened longitudinally from above. (C) A bovine pericardial patch is used to enlarge the ostium.
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Taking advantage of the horizontal aortotomy routinely utilized, a vertical incision was opened just above the coronary ostia and prolonged onto the coronary roof for a few millimeters (Fig 1B). A bovine pericardial triangular patch, slightly wider than the ostium main transverse diameter and about 10–12 mm in length, was then sutured in place as an onlay patch in order to enlarge each ostium above the prosthetic annular level (Fig 1C). Meticulous attention was devoted to avoid redundant patch in an attempt to minimize potential complications such as thromboembolic events and dilatation. The aortotomy was then closed paying attention to match properly the two lines of suture of different length due to the presence of the patch's superior edge proximally.
All patients had an uneventful postoperative course. At a mean follow-up of 58 months they are all asymptomatic in NYHA FC I, with a normal electrocardiogram (ECG), negative stress test, and a normal functioning prosthetic valve on two-dimensional (2D)-echocardiography. An aortogram performed one year postoperatively in the 66-year-old lady after both ostial enlargement showed normal coronary perfusion (Fig 2).
Serial 2D echocardiographies performed yearly in all patients did not show any enlargement or aneurismal dilatation of the patch.
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Fig 2. Aortic root angiogram showing unobstructed coronary ostia (nonselective injection). (LMCA = left main coronary artery; RCA = right coronary artery.)
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Comment
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Coronary ostia stenosis after aortic valve replacement determined by the device is a dreadful complication with a high mortality rate if left untreated [1–6]. Prompt recognition of the problem is mandatory and usually implies device removal and/or re-replacement with a smaller valve size with or without annular enlargement. This approach may be difficult, particularly in patients with small aortic root, and result in a very long ischemia time with possible subsequent myocardial dysfunction. A coronary artery bypass graft may also be performed as a possible solution but might lead to quite a suboptimal long-term result especially in young patients. Similarly a translocation of the coronary ostium to a higher position at the aortic root level may be very difficult to accomplish in this setting being the coronary ostia partially hidden by the prosthetic device already tied down in its final position (Fig 1A).
There is no need to say that the best way to manage complications is to prevent them. During aortic valve replacement an appropriate sizing of the annulus associated with an accurate identification of all the anatomical landmarks, particularly coronaries take-off, is mandatory to perform a successful procedure.
However the complication presented may indeed occur and the technique herein presented being reproducible, with the only possible exception for those cases with diffuse calcification of the aortic root and/or of coronary ostia, might be of some help in selected circumstances.
Indeed the possible use of a patch to achieve the optimal coronary take-off from the neo-aortic root has already been recognized for many years in pediatric cardiac surgery particularly in the repair of d-transposition of the great arteries with complex coronary anatomy [7].
As far as patch material is concerned, having the aorta clamped and facing an unpredicted problem, the use of bovine pericardium in our experience was mostly dictated by the need to save time thus choosing the first readily available material. Although no complications were seen at follow-up related to this variable, other materials such as glutaraldehyde-pretreated pericardial patch, saphenous vein path, or mammary artery segments might be used if made readily available by circumstances.
In conclusion the technique reported offers the chance to manage a nasty complication with the advantage of saving time compared with alternatives such as prosthetic valve take-down with or without aortic root enlargement or more complex procedures such as coronary translocation and avoids conventional myocardial revascularization. Our follow-up proves its safety and durability in the midterm.
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References
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- Castaneda A.R., Jonas R.A., Mayer J.E., Hanley F.L. Cardiac surgery of the neonate and infant. . Philadelphia, PA: W.B. Saunders Company, 1994.
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