Successful Treatment of Compression of an Anomalous Circumflex Artery After Aortic Valve Replacement With Percutaneous Coronary Intervention

Percutaneous Coronary Intervention Through a Retrograde Approach in Complete Occlusion of the Coronary Ostium Following Surgical Aortic Valve Replacement

“…4) This complication could occur in the left main coronary artery, in the RCA, or in both. Several pathophysiologic mechanisms have been suggested, and these include coronary spasm, debris/ thrombus embolization from the aortic valve or wall, [5][6][7] and intraoperative iatrogenic causes, such as extraluminal compression (e.g., the surgical material, the suture used to close, hematoma) 8) or vessel transection (e.g., vessel kinking). 4,9) The usual symptoms and clinical findings of COS after SAVR include the development of unstable angina, which could be treated by either CABG 1,2) or PCI.…”

“…4,9) The usual symptoms and clinical findings of COS after SAVR include the development of unstable angina, which could be treated by either CABG 1,2) or PCI. 4,8,10) Advancements in the techniques and instruments over the past 20 years have led to the increased utility of PCI to successfully treat COS, and favorable outcomes have been achieved compared to early repeat surgery.…”

Anomalous left circumflex coronary artery entailing a risk of compression following valve surgery: a caveat regarding preoperative diagnosis

“…I enjoyed reading the report by Papakonstantinou et al [1] about 25 patients with an anomalous right aortic sinus-or right coronary artery (RCA)-connected retroaortic left circumflex coronary (LCx) artery who underwent isolated surgical aortic valve replacement (AVR; 20 patients), combined AVR and mitral valve replacement (MVR; 3 patients) or tricuspid valve annuloplasty (1 patient) and isolated MVR (1 patient). Eleven of these patients developed postoperative compression of the anomalous LCx artery which was caused by the sewing ring(s) of the prosthetic valve(s) (9 patients) or by an annular suture (1 patient) [2][3][4][5][6][7][8][9]. In four of these eleven patients, the anomalous LCx artery had not been diagnosed preoperatively because an angiogram had not been performed (3 patients) or because of failure to suspect and hence angiographically demonstrated the anomaly (1 patient) resulting in failure to apply a tailored surgical approach aiming in preventing the complication [2][3][4].…”

“…Eleven of these patients developed postoperative compression of the anomalous LCx artery which was caused by the sewing ring(s) of the prosthetic valve(s) (9 patients) or by an annular suture (1 patient) [2][3][4][5][6][7][8][9]. In four of these eleven patients, the anomalous LCx artery had not been diagnosed preoperatively because an angiogram had not been performed (3 patients) or because of failure to suspect and hence angiographically demonstrated the anomaly (1 patient) resulting in failure to apply a tailored surgical approach aiming in preventing the complication [2][3][4]. In the remaining seven cases, the anomalous LCx artery had been diagnosed preoperatively [5][6][7][8][9], however, a tailored surgical approach had been applied only in four cases and concerned isolated aortic valve (AV) prosthesis downsizing.…”

“…In four of these five patients a tailored surgical approach had not been applied and an antemortem diagnosis of the complication had not been accomplished [2,5,9]. Of seven patients diagnosed with the complication in question, two patients were treated by redo-surgery (bypass grafting combined with complete mobilization of the anomalous LCx artery away from the aortic annulus [1 patient] and AVR using an undersized prosthesis [1 patient]), four patients underwent stent angioplasty and one patient was managed conservatively [3,4,[6][7][8]. Some conclusions can be gleaned from these data.…”