Asian Cardiovasc Thorac Ann 2002;10:367-368
© 2002 Asia Publishing EXchange Pte Ltd
Acute Right Coronary Artery Embolus After Aortic Valve Surgery
Mouhcine Abid-Allah, MD,
Khalid Al Jubair, FRCS
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Department of Cardiac Surgery Prince Sultan Cardiac Center Riyadh, Saudi Arabia
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For reprint information contact: Mouhcine Abid-Allah, MD Tel: 966 1 477 7714 Ext. 4774 Fax: 966 1 476 0543 email: obaidmuhcin{at}hotmail.com L515 Military Hospital, P.O. Box 7897, Riyadh 11159, Saudi Arabia.
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ABSTRACT
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A 35-year-old man with rheumatic aortic valve regurgitation developed acute right ventricular failure 8 days after valve replacement with a mechanical prosthesis. Angiography showed a right coronary artery embolus. Successful coronary artery bypass grafting was performed on the beating heart.
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INTRODUCTION
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Acute myocardial ischemia following aortic valve replacement is a rare complication. The reported causes are variable and include mechanical problems and particulate matter embolization.
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CASE REPORT
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A 35-year-old man was investigated for dyspnea and asthenia. Physical examination showed a mixed aortic ejection and diastolic murmur radiating down the sternum. Blood pressure was 130/50 mm Hg, heart rate was 70 beats per minute in sinus rhythm, and there were no signs of right ventricular failure. He reported a history of episodes of sore throat in childhood. Chest radiography indicated mild cardiac enlargement. Echocardiography demonstrated severe aortic regurgitation with mild to moderate aortic stenosis. The aortic valve area was estimated as 1.5 cm2. The left ventricle was slightly dilated with good left ventricular function. Surgery was performed through a midline sternotomy with moderate hypothermia, cardiopulmonary bypass, and continuous blood cardioplegia. The aortic leaflets were found to be very thick and retracted at the edges with no coaptation. There was slight fusion of the commissures but no calcification. A 23-mm mechanical aortic valve was inserted. The aortic crossclamp time was 55 minutes. The patient come off cardiopulmonary bypass easily and in sinus rhythm. He was transferred to the intensive care unit and extubated that night. His postoperative course was smooth. Echocardiography showed a well-placed mechanical valve functioning properly with no leakage and a gradient of 10 mm Hg. He was discharged on postoperative day 6 with an international normalized ratio of 3.2. Two days later, he was readmitted urgently in cardiac shock one hour after the onset of sudden chest pain. There were signs of right ventricular failure and hepatomegaly that was painful on palpation, with hepatojugular reflux. An electrocardiogram showed first-degree atrioventricular block and ST-segment elevation in leads III, aVF, V1, and V2. Echocardiography demonstrated no pericardial effusion, good left ventricular function, and dilation of the right ventricle. A thrombus in the middle segment of the right coronary artery 2 cm from the coronary ostia was observed on angiography. The patient underwent urgent reoperation. His right ventricle was found to be akinetic. Right coronary artery bypass was performed on the beating heart using a saphenous vein graft. The atrioventricular block disappeared and the right ventricle resumed movement 15 minutes after completing the anastomosis. During a short stay in the intensive care unit, the right ventricle recovered normal size and contractility. Before discharge, hematological investigations showed no coagulation problem.
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DISCUSSION
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Acute occlusion of a coronary artery by an embolus following valve surgery is uncommon. The diagnosis is usually easy when the symptoms are obvious, the hemodynamic consequences are significant, and they appear after a certain lapse of time postoperatively. Investigations such as echocardiography, electro-cardiography, and angiography are the keys to diagnosis. A coronary angiogram may show complete or partial occlusion of the coronary artery lumen. However, it is sometimes difficult to ascertain the diagnosis and particularly to differentiate between a coronary embolus and a mechanical problem. Indeed, coronary occlusion due to a mechanical problem is easier to diagnose because it usually manifests during surgery as failure to wean off cardiopulmonary bypass, and the right ventricle can be seen to be immobile and dilated.1 Cardiopulmonary bypass should be re-instituted to evaluate the position of the valve and check the coronary ostia; the cause is often malpositioned leaflets obstructing the right coronary ostia or a deep stitch taking in the right coronary ostia from the annulus side. On the other hand, the diagnosis of a coronary embolus depends on certain factors such as the time of onset of ischemia and the type of embolus.
Reported causes of embolism are variable and include migration of intracardiac particulate matter from a calcified aortic valve, papillary muscle, or aortic vegetation.2–5 Myocardial ischemia secondary to a paradoxical embolus resulting from peripheral venous thrombus or after cardiac catheterization has also been reported.1,6 In this case, the cause of the embolus was probably a thrombus that formed and migrated during a period of abnormal hemostasis. Management of this complication is usually by grafting the occluded vessel. Some cases have been treated by Fogarty catheter embolectomy combined with aortocoronary bypass.3 Complete recanalization has been achieved in a few patients by percutaneous transluminal coronary angioplasty using a local fibrinolytic agent.7,8 In this patient, intracoronary thrombolysis was indicated, but he became more unstable during the angiography procedure, and coronary artery bypass grafting was considered appropriate because of the recent sternotomy (8 days previously).
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REFERENCES
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- Salerno TA, Bergsland J, Calafiore AM, Cordell AR, Kon ND, Bhayana JN. Acute right ventricular failure during aortic valve operation due to mechanical problem in the right coronary artery. Ann Thorac Surg
1996;61:706–7.[Abstract/Free Full Text]
- Folliguet TA, Malergue MC, Temkine J, Dibie A, Petrie J, Laborde F. Calcified embolus of the left coronary ostia after aortic valve replacement. Ann Thorac Surg
1997;63:1162–3.[Abstract/Free Full Text]
- Pifarre R, Grieco J, Sullivan HJ, Scanlon PJ, Johnson SA, Gunnar RM. Coronary embolism: surgical management. Ann Thorac Surg
1980;30:564–8.[Abstract]
- Loisance D, Aubry P, Heulin A, di Matteo J. Embolism in a fragment of the mitral papillary muscle to the left main coronary artery. A rare complication of valve replacement [French]. Arch Mal Coeur Vaiss
1979;72:1029–33.[Medline]
- Shamsham F, Safi AM, Pomerenko I, Salciccioli L, Feit A, Clark LT, et al. Fatal left main coronary embolism from aortic valve endocarditis following catheterization. Catheter Cardiovasc Interv
2000;50:74–7.[Medline]
- Waller BF, Dixon DS, Kim RW, Roberts WC. Embolus to the left main coronary artery. Am J Cardiol
1982;50:658–60.[Medline]
- Taniyasu N, Seino R, Sawatani O, Yano T, Inoue S, Haruta S, et al. A case of coronary artery embolism after double valve replacement [Japanese]. Kyobu Geka
1996;49:583–6.[Medline]
- Quinn EG, Fergusson DJ. Coronary embolism following aortic and mitral valve replacement; successful management with abciximab and urokinase. Catheter Cardiovasc Diagn
1998;43;457–9.[Medline]
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ABSTRACT
INTRODUCTION
