atrogenic coronary ostial stenosis (ICOS) following aortic valve replacement (AVR) is a rare but potentially lethal complication. Stenosis of the left main trunk (LMT) and ostium of the right coronary artery (RCA) after AVR was first described by Roberts and Morrow in 1967 1 and the incidence of this complication following AVR has been estimated as between 1% and 5%. [2][3][4][5][6][7] Clinical symptoms are often severe and may appear within the first 6 months. The underlying cause remains undetermined. To date, the diagnosis has been made by repeat angiography and the usual treatment has been aortocoronary bypass surgery, but recently some cases treated with balloon angioplasty and stenting (percutaneous coronary intervention (PCI)) have been reported. [8][9][10][11][12][13] We present 3 cases of ICOS treated with PCI. Case Reports Case 1A 61-year-old woman with a history of hypertension was referred because of fatigue and dyspnea on exertion. On admission the ECG showed sinus rhythm and left ventricular (LV) hypertrophy. Preoperative coronary angiography demonstrated normal coronary arteries and severe calcific aortic valve stenosis. The echo-Doppler revealed a peak aortic gradient of 90 mmHg, mild aortic regurgitation, and an aortic valve area of 0.7 cm 2 with normal LV function. We performed a modified Bentall procedure with the button technique. The patient's tricuspid valve was thickened, and extremely calcified. Coronary arteries were reconstructed with a full root technique. There was no displacement or flexion of the coronary artery graft during the surgical procedure. Myocardial protection with intermittent direct coronary cold blood cardioplegia was used. The first dose was administered by retrograde infusion from the coronary sinus (retro-cannula, RC014I, 14Fr, 4.7 mm, Edwards), and subsequently by antegrade direct cannulation of both coronary ostia using flexible, balloon-tipped cannulae (coronary perfusion cannula, Polystan). A Freestyle Prima PLUS 19-mm stentless valve (Edwards Lifesciences) was used to replace the native valve and aortic root using the full root technique. The patient made a complete recovery and was discharged on oral warfarin. Two months later she experienced severe chest pain and had a syncopal attack, and was taken to the center by ambulance. On admission the ECG showed transient ST-segment depression of 2 mm in the precordial leads, II, III, and aVF (Fig 1). Physical examination revealed normal prosthetic valve sounds, a grade 4/6 systolic ejection murmur at the right second intercostal space, and absence of rales at the base of the lungs. There was no pedal edema. Echocardiography showed normal function of the left ventricle. Repeat coronary angiography showed severe (75%) LMT stenosis and 90% stenosis of the ostium of the RCA (Fig 2). Coronary bypass surgery was recommended as the first therapeutic option, but was rejected by the patient. For this reason she was scheduled for urgent PCI. On the same day PCI of the RCA was performed using a Runway FR3.5 6F guiding catheter ...

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We examined the relationship between flow-mediated dilation (FMD) of the brachial artery and the extent and severity of coronary artery disease (CAD). Using high-resolution ultrasonography, we measured FMD and nitroglycerin-induced brachial artery dilation. We studied 121 patients (77 men, 44 women; mean age 64+/-11 years, range 25-79 years) who underwent coronary arteriography. The extent and severity of CAD were assessed by the coronary stenosis index (CSI). The adjusted FMD correlated inversely with CSI (rs=-0.63, p<0.0001). Multivariate analysis demonstrated that the adjusted FMD was an independent predictor of CSI. The adjusted FMD was 10.2+/-4.8% in patients without CAD (n=32), 7.7+/-6.0% in patients with single-vessel disease (n=31), 5.2+/-5.5% in patients with double-vessel disease (n=29), and 2.0+/-3.9% in patients with triple-vessel disease (n=29). The adjusted FMD was significantly lower in the double- (p<0.01) and triple-vessel (p<0.0001) disease groups than in patients without CAD. The adjusted FMD was significantly lower in the triple-vessel disease group than in the single-vessel disease group (p<0.001). Based on our results, as coronary atherosclerosis becomes more severe, the adjusted brachial artery FMD becomes more severely impaired.

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