Bilateral coronary artery occlusion after aortic valve replacement in a patient with porcelain ascending aorta
1 Department of Cardiology, La Paz University Hospital, Madrid, Spain
2 Department of Pathology, La Paz University Hospital, Paseo de la Castellana 261, 28046 Madrid, Spain
* Corresponding author. E-mail address: asanchezr.hulp{at}salud.madrid.org
A 75-year-old woman with diabetes and chronic renal failure underwent aortic valve replacement (St. Jude Medical Biocor 21 mm, St Paul, MN, USA) for severe aortic stenosis. Pre-operative cardiac catheterization showed normal coronary arteries and a severe calcification of the aortic valve and the ascending aorta (Panel A). The patient suddenly had chest pain with hypotension on day 12 after surgery. The ECG suggested an inferior acute myocardial infarction. Emergency coronary angiography revealed total ostial occlusion of the right coronary artery (Panel B, black arrow) and a mobile intraluminal filling defect in the left main coronary artery (Panel B, white arrow). The patient developed electromechanical dissociation and died during catheterization. Necropsy showed severe atherosclerotic disease of the ascending aorta and accumulation of calcium-like material between the prosthesis and the aortic root wall, which completely occluded the right coronary ostium (Panel C). The left main coronary artery was patent. Histochemical analysis confirmed the presence of calcified fragments of atheromatous plaque located around the aortic prosthesis (Panel D).
It can be speculated that the manipulation of an atherosclerotic ascending aorta during cardiac surgery and the erosion produced by the prosthesis stent in the wall of a small-sized calcified ascending aorta could have precipitated the accumulation of calcium-like material around the aortic prosthesis. This material might as well be responsible for the mobile left coronary occlusion. This case emphasizes the risk of cardiac surgery in patients with severely diseased ascending aorta.
Panel A. Pre-operative cardiac catheterization. Fluoroscopic image showing an extensive calcification of the mitral annulus, and severe calcification of the ascending aorta and the aortic valve. Aortography shows moderate aortic regurgitation and coronary angiograms are normal. RCA, right coronary artery; LCA, left coronary artery.
Panel B. Emergency aortography performed during inferior myocardial infarction shows a total ostial occlusion of the right coronary artery (black arrows) and a mobile intraluminal filling defect in the left main coronary artery which moves during both phases of the cardiac cycle (white arrows).
Panel C. Macroscopic examination shows an atherosclerotic aortic root with a transverse competent suture and a biological prosthesis without thrombotic material in its valves. An accumulation of calcium-like material is identified between the aortic prosthesis and the aortic root, which is more abundant in the right side (black arrows). The white arrows point to the left coronary ostium.
Panel D. Microscopic analysis demonstrates fragments of atheromatous plaque with macrophages, lymphocytes, cholesterol crystals, and important deposits of calcium (purple crystals) located around the aortic prosthesis (HE 100x).
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