Author + information
- Received April 5, 2016
- Revision received April 27, 2016
- Accepted May 5, 2016
- Published online August 8, 2016.
- Marta López Castillo, MD∗ (, )
- Roberto Martín Reyes, MD,
- Julia Palfy, MD,
- Juan Antonio Franco, MD, PhD,
- Antonio Piñero, MD,
- Felipe Navarro, MD,
- Marta Tomás, MD,
- Gonzalo Aldámiz, MD and
- Jerónimo Farré, MD, PhD
- Department of Cardiology, Hospital Universitario Fundación Jiménez Díaz-Quirónsalud, Universidad Autónoma de Madrid, Madrid, Spain
- ↵∗Reprint requests and correspondence:
Dr. Marta López Castillo, Avenida Reyes católicos 2, 28003, Madrid, Spain.
A 74-year-old woman was admitted to the intensive care unit with acute pulmonary edema requiring endotracheal intubation. The presence of an unknown critical aortic stenosis was revealed with markedly calcified mitral annulus and preserved left ventricular ejection fraction. Because the patient presented rapid clinical deterioration, urgent surgical aortic valve replacement (AVR) with a biological prosthesis was carried out without performing a coronary anatomy study, because of the hemodynamic instability of the patient.
Twelve hours after the procedure, the patient developed 2:1 atrioventricular block and inferolateral ST-segment elevation. Suspecting an ST-segment elevation myocardial infarction, emergent coronary angiography was performed. The study revealed that the left circumflex coronary artery (LCx) originated independently from the right coronary sinus, with a retroaortic trajectory. This anomalous artery was compressed between the aortic prosthetic ring and the calcified anterior mitral annulus, conditioning an extensive inferolateral myocardial ischemia (Figure 1A). Because of the poor condition of the patient, the high suspicion of compression and nonsurgical ligation as the mechanism of ischemia, and the immediate availability of treatment, percutaneous coronary intervention was indicated. A straightforward angioplasty was performed, and 2 drug-eluting-stents were implanted without any complication, fully relieving the compression (Figure 1B). A few weeks later, coronary computed tomography confirmed the anomalous rise and retroaortic trajectory of the LCx with the 2 patent drug-eluting stents and no residual stenosis (Figures 1C to 1F).
After a prolonged in-hospital recovery, the patient was ultimately discharged home under optimized medical therapy, with normal left ventricular ejection fraction and a normally functioning aortic bioprosthesis.
The increased risk for myocardial ischemia in patients with anomalous origin of the LCx undergoing AVR has been previously described. This can happen because of prosthetic compression of the LCx at its retroaortic segment or the ligation of the coronary artery by annular suture. To the best of our knowledge, this is the first reported case of ST-segment elevation myocardial infarction caused by compression of an anomalous LCx after AVR between the bioprosthesis and a severely calcified anterior mitral annulus that was successfully treated percutaneously, so that a second surgical intervention could be avoided. In patients with retroaortic course of the LCx and post-operative AVR ischemia, coronary artery compression or surgical ligation must be suspected and ruled out. If there is high suspicion of compression as the mechanism of ischemia, percutaneous coronary intervention can be a reasonable treatment option.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received April 5, 2016.
- Revision received April 27, 2016.
- Accepted May 5, 2016.
- American College of Cardiology Foundation