122 |
Letters to the Editor
International Cardiovascular Forum Journal 8 (2016)
DOI: 10.17987/icfj.v8i0.279
An Unexpected Cause Of Acute Coronary
Syndrome: Iatrogenic Right Coronary
Dissection as a Delayed Complication After
Valve Replacement Surgery
Ana Redondo Palacios, José López Menéndez, Laura Varela Barca,
Miren Martín García
Hospital Ramón y Cajal, Madrid, Spain
Corresponding author:
Dr. Ana Redondo Palacios
Cardiovascular Surgery
Hospital Ramón y Cajal
Carretera Colmenar Viejo km 9,100. 28034 (Madrid , Spain)
Tel.: +34 91 338 86 51
Email: [email protected]
Highlights
Coronary artery dissection is an infrequent complication, which in an important number of cases has an iatrogenic cause. Most
of them occur after a percutaneous procedure, and usually the right coronary artery is the one affected. We report the case of an
iatrogenic right coronary dissection after valve replacement surgery. The cause was assumed to be the antegrade cannulation
of the ostium for cardioplegic perfusion. What we consider particularly interesting about this case is that it had a delayed clinical
manifestation, 9 days after surgery, having a normal immediate post-operative course. The diagnosis was achieved by coronary
angiography, and no interventional treatment was performed.
Keywords:
Coronary dissection, iatrogenic, ostium, cardioplegia
Citation:
Redondo Palacios A, López Menéndez J, Varela Barca L, Martín García M.An unexpected cause of acute coronary
syndrome: Iatrogenic right coronary dissection as a delayed complication after valve replacement surgery.
International Cardiovascular Forum Journal 2016;8:122-123. DOI: 10.17987/icfj.v8i0.279
Coronary artery dissection is a quite unusual but eventually lifethreatening complication, and most cases occur as an immediate
adverse event after cardiac catheterization [1, 2]. Mostly, it affects
the right coronary artery, due to its anatomical disposition [3].
Rarely it can affect the LMCA (1% of all procedures), as happened
in the case reported, and it can have fatal consequences if the
adequate management fails to be administered. Usual treatment
comprises not only percutaneous intervention, but also surgical
myocardial revascularization as long as patient’s haemodynamic
stability can be achieved. But not only interventional procedures
can be the cause of this complication. It has also been reported
to occur in the scenario of a cardiac surgery procedure, despite
being a much less frequent complication [4]. In the absence of
any other explanation, the cause was assumed to be endothelial
lesion due to the direct antegrade cannulation of the coronary
ostia, for cardioplegic perfusion. Its clinical presentation is usually
intraoperative or immediate post-operative ischemia, when a rapid
management and usually surgical treatment is required, but it can
* Corresponding author. E-mail: [email protected]
also show up even more than a week after surgery, becoming a very
unusual complication that should be considered in these patients,
when they have a post-operative acute coronary syndrome.
The case we present is an 80-year-old woman, with the preoperative
diagnosis of severe aortic stenosis and moderate mitral regurgitation.
She had permanent atrial fibrillation, and the angiography done in
order to rule out coronary disease was normal. She underwent a
mitral and aortic valve replacement; cardioplegic solution perfusion
was delivered by direct cannulation through coronary ostia, with a
3-mm rigid cannula (Coronary Perfusion Cannula 9 F, Sorin Group).
No unexpected events were reported during the intervention. After
weaning off pump, there were no heart rhythm abnormalities or
any other EKG alterations. The patient had a satisfactory postoperative course. Troponin I peak levels were within normal values
in the second day after surgery (3.4 ng/mL). She was discharged the
seventh post-operative day, without any chest pain during all the
admission, and in a good functional class (NYHA II/IV).
ISSN: 2410-2636 © Barcaray Publishing
International Cardiovascular Forum Journal 8 (2016)
DOI: 10.17987/icfj.v8i0.279
Letters to the Editor
| 123
Two days after discharge, the patient was brought to the Emergency
Room because of an episode of syncope, with the EKG revealing
a blocked atrial fibrillation with right bundle branch block, and STsegment elevation (Fig. 1). The lab test showed increased levels
of myocardial damage enzymes (Troponin I peak level 28.2ng/mL).
The patient was taken to the catheter lab for a diagnostic coronary
angiography, which revealed the existence of an antegrade
dissection all along the right coronary artery, with no blood flow
compromise (TIMI Grade flow of 3) (Fig. 2). Since there was complete
filling of the distal vascular bed, no interventional procedure was
performed. The patient had a satisfactory progress afterwards with
medical management, and she was discharged six days after her
admission, asymptomatic and in a good functional class. No further
adverse events were reported during her follow-up.
Nowadays, more elderly patients undergo major cardiac surgery,
most of them with many associated pathologies; as a direct
consequence of this, a bigger proportion of them have fragile tissues,
atheromatosis, and calcified arterial walls. In this context, iatrogenic
coronary arterial dissection is no longer an exclusive complication
in the interventional field, but it’s also increasing its frequency in
surgical procedures. The most frequent iatrogenic arterial dissection
associated to surgery is aortic (that has been reported to have an
incidence up to 0.6%). Coronary artery iatrogenic dissection is quite
less common, and only some isolated cases have been reported
by now. Most of them are discovered intraoperatively, or within the
first 72 hours after surgery [5]. The main cause has been assumed
to be in all cases the direct antegrade perfusion of cardioplegia
through the coronary ostia, since the flow pressure of the perfusion
along with the frailty of the coronary tissues (specially in the elderly
patients) are believed to cause the arterial wall lesion. Another
adverse event which has been related to these same factors is
coronary ostium stenosis [6], since the cannula trauma produces a
proliferative fibrosis of the arterial intima layer.
The case we report here turns out to be a late finding of this
complication, which develops as an acute coronary syndrome
nine days after surgery, with a syncope episode, EKG alterations
and cardiac enzymes elevation. The final diagnose in this case
was achieved through a coronary angiography, but a CT-scan
could also be performed, especially in patients who have recently
undergone surgery, as it’s a less invasive test.
Figure 1. This image shows the ECG prior to the admission of the
patient in the Emergency Room, right after the syncope. It reveals
atrial fibrillation with right bundle branch block. Furthermore, an
ST-segment elevation can be seen in DIII, aVF and V3-V5 leads;
with ST depression in aVL.
Figure 2. An image of the coronariography performed during the
second admission. The white arrows point at the image in the
right coronary artery which was misdiagnosed at first as an spiral
thrombus. Finally, reviewing the images and taking into account
the previous surgery, the final diagnosis of coronary dissecion
was achieved.
Conservative treatment can be an option for these patients
(especially when it affects the right coronary artery), as long as
the flow through the damaged vessel gets no compromise, with
good results and no reported adverse events in the mid-term
follow-up.
Declarations of interest
The authors declare no conflicts of interest.
Acknowledgements
The authors agree to abide by the requirements of the “Statement
of publishing ethics of the International Cardiovasular Forum
Journal [7].
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