Commentary
Acute Myocardial Infarction Ten Days after Bentall Procedure due to Coronary Embolism: Etiology Discussion and Rare Case Presentation
Paolo Nardi*, Marco Russo, Monica Greci, Calogera Pisano, Guglielmo Saitto, Giulio Pellegrini, Antonio Pellegrino, Carlo Bassano, Antonio Scafuri and Giovanni Ruvolo
Department of Cardiac Surgery, Tor Vergata University Policlinic, Rome, Italy
*Corresponding author: Paolo Nardi, Department of Cardiac Surgery, Tor Vergata University Policlinic, Viale Oxford 81, 00133 Rome, Italy
Published: 04 Oct, 2018
Cite this article as: Nardi P, Russo M, Greci M, Pisano C,
Saitto G, Pellegrini G, , et al. Acute
Myocardial Infarction Ten Days after
Bentall Procedure due to Coronary
Embolism: Etiology Discussion and
Rare Case Presentation. Clin Surg.
2018; 3: 2136.
Abstract
Coronary thromboembolism is a rare cause of acute coronary syndromes (ACS, i.e. STEMI) and the
data regarding ACS in patients with prosthetic heart valve are poor and based mainly on case report.
The likelihood of this focal coronary problem with normal coronary arteries is between 1% to 5%
and several mechanisms have been proposed and reported.
We here present the single case of a distal left circumflex artery embolism after Bentall procedure
and hemiarch resectionin the setting of an acute type A aortic dissection successfully managed with
conservative therapy and a brief comment on the actual literature.
Commentary
Coronary occlusion is a rare complication after aortic and mitral valve surgery [1]. In literature
some cases of prosthetic heart valve thrombosis-derived coronary embolism have been reported
and several pathophysiologic mechanisms for this kind of event have been proposed. This event
represents a rare cause of acute coronary syndromes (ACS, i.e. STEMI) and the data regarding ACS
in patients with prosthetic heart valve are poor and based mainly on case report [1-2]. The likelihood
of this focal coronary problem with normal coronary arteries is between 1% to 5% [3].
Karakoyun and co-authors described three cases of prosthetic valve thrombosis causing non-ST
elevation ACS, who was successfully treated with thrombolytic therapy [4]. Leontyev and colleagues
described also a case of embolic occlusion of the left main coronary artery following an isolated
aortic valve replacement treated with emergent coronary artery bypass grafting [5].
Iatrogenic Coronary Ostial Stenosis (ICOS) could be associate with several mechanisms that
have been previously described. Tukiji et al. reported that immunological reaction to the heterograft
was a potential mechanism causing ostial coronary artery stenosis [6-7]. More, the direct coronary
perfusion for myocardial protection during aortic valve surgery may produce immediate traumatic
lesions and latest stenosis of the coronary arteries. Micro-injuries and local pressure necrosis might
be related to the infusion pressure of the cardioplegic solution and over-dilatation of the vessel
by the selective cannulation to delivery cardioplegia. In addition, intimal thickening and fibrous
proliferation in proximity to the aortic root as a reaction to the turbulent flow around the prosthetic
valves, as well as particulate embolism into the coronary arteries potentially related with a subtherapeutic
oral anticoagulation in patients with mechanical prostheses (Figure 1). Symptoms
of ICOS, which usually develop within 6 months of surgery, can be rapidly progressive and may
include angina pectoris, left ventricle failure or acute pulmonary oedema. These complications
require prompt clinical recognition and early treatment because of the possibility of sudden death.
In other cases reasons of myocardial ischemia can be acute coronary occlusion by ostial
obstruction by the valve prosthesis or arterial dissection due to cardioplegia’s cannula trauma.
A sub-therapeutic oral anticoagulation could represent although rarely the main aetiology of an
acute coronary events. Management of those complications are based on interventional or surgical
procedures, or on medical therapy with thrombolytic therapy.
Here we present the case of a 53 years-old man affected by acute Type A aortic dissection underwent
Bentall procedure and hemiarch resection with mechanical composite graft CarboMedics 25/28
mm,(CarboMedics, Carboseal, Livanova, Saluggia, Vercelli, Italy) due to moderate hypothermia and
bilateral anterograde cerebral perfusion. A complete dissection of Valsalva sinus and both coronary
ostia were also detected during surgical inspection. The immediate
post-operative course was event free. Postoperative CT-scan showed
optimal result of the Bentall operation and post-processing analysis
showed no alterations of coronary arteries. In postoperative day 9
the patient has been transferred for rehabilitation. In POD 10, he
presented a single episode of angina at rest, autonomously solved,
with 1mm to 2 mm ST-elevation in inferior derivations and increase
of myocardial enzymes with a peak of troponin I of 34917, 1 ng/L,
and peak of CK-MB 103,20 ng/mL). The patient was under oral
anticoagulation with warfarin. INR was 1,74 and 60,00 units of
enoxaparin every 12 hrs had been administered subcutaneously in
the previous days.
Due to the diagnosis of ST Elevation Myocardial Infarction
(STEMI) he underwent coronary angiography that revealed an
embolic occlusion of the distal territory of the left circumflex coronary
artery, anyway with flow TIMI III, while the other coronary vessels
and the reimplanted coronary ostia on the composite graft conduit
were free from acute or chronic lesions. Because of presence of a
distal occlusion and the stable clinical setting a conservative strategy
was adopted, and a medical therapy with double antiplatelet therapy,
in association with warfarin and beta-blockers, was started. A
complete regression of ECG alterations and the absence of symptoms
characterized the hospitalization course and the echocardiography
before discharge confirmed good global left ventricular function,
i.e. LVEF 0,60. Patient was discharged 5 days after STEMI. At one
month of follow-up he was in optimal clinical conditions, NYHA
class I, and absence of angina, without any alteration in ECG and
echocardiography, and the same medical therapy was continued.
To the best our knowledge this is the first report of such
complication described in the setting of a Bentall procedure for acute
Type A aortic dissection and successfully treated with combination of
dual antiplatelet medication in association with oral anticoagulation
therapy.
Several considerations can be deduced. International guidelines
suggest a target INR of 2.5 for patients with mechanical aortic valve
prosthesis in absence of other risk factors. In the present case, even
if the patient’s INR was 1.79, the contemporary therapeutic dose
of enoxaparin should cover from embolic events. Nevertheless, an
aggressive oral anticoagulation should be evocated for all patients, and
in some cases, addition of a low dose of aspirin could represent a valid
option. This combination could decrease thromboembolic events,
while on the other hand, could cause an important increase of the
risk of bleeding. For this reason it was not used in the present patient
according to the risk of pericardial effusion after surgical operation.
More, a conservative therapy was successful in this case, most of all
for the rapid and autonomous resolution of the clinical setting. In
fact, the risk of the possible interventional treatment procedure with a
percutaneous coronary stenting to treat the coronary occlusion should
be balanced with the clinical setting of a patient recently treated for
aortic dissection, in which the recent coronary ostia sutures were at
possible high risk for dehiscence or fatal bleeding during guide wires
manipulation.
In conclusion, even if coronary embolism is a rare cause of
myocardial infarction, it should be well known and rapidly recognized
in order to achieve the optimal management.
Figure 1
Figure 1
Coronary angiography shows the acute occlusion of the distal tract
of the left circumflex coronary artery due to embolism.
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