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Year : 2020  |  Volume : 7  |  Issue : 3  |  Page : 313-317

Acute coronary disruption after Bentall’s procedure: outcome and the role of emergency coronary angiography

King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia

Date of Submission09-Jun-2019
Date of Acceptance08-Apr-2020
Date of Web Publication29-Sep-2020

Correspondence Address:
MD,PhD Mohamed Laimoud
King Faisal Specialist Hospital and Research Center, Heart Center P.O. Box 3354, Riyadh 11211
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/roaic.roaic_47_19

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Coronary ostial stenosis is a rare but fatal consequence of aortic root surgery. Clinical presentations can include ventricular arrhythmias, acute coronary syndromes, congestive heart failure, or sudden death. Three interesting cases of acute coronary disruption after Bentall’s procedure were presented, with each case having a different outcome. The first case was a 56-year-old male patient admitted for elective Bentall’s procedure and developed inferoposterior STEMI complicated with ventricular fibrillation. After resuscitation, emergency percutaneous coronary intervention (PCI) and stenting of right coronary artery were performed successfully. The second case was a 39-year-old female patient admitted for Bentall’s procedure and was complicated with ventricular tachycardia with hemodynamic collapse necessitating venoarterial extracorporeal membrane oxygenation and emergency PCI to the left main coronary artery. The third case was a 41-year-old woman admitted for Bentall’s procedure and was complicated with fatal ventricular arrhythmias. After venoarterial extracorporeal membrane oxygenation and coronary angiography, emergency coronary artery bypass graft was done. Conclusion: Acute coronary ostial stenosis may occur after aortic root surgery and this complication may be life threatening and may lead to myocardial infarction or fatal ventricular arrhythmia. PCI with stenting is safe and effective after aortic root surgery and is an efficient alternative to coronary artery bypass graft.

Keywords: Aortic root, Bentall’s procedure, coronary angiography, percutaneous coronary intervention, VA-ECMO

How to cite this article:
Laimoud M. Acute coronary disruption after Bentall’s procedure: outcome and the role of emergency coronary angiography. Res Opin Anesth Intensive Care 2020;7:313-7

How to cite this URL:
Laimoud M. Acute coronary disruption after Bentall’s procedure: outcome and the role of emergency coronary angiography. Res Opin Anesth Intensive Care [serial online] 2020 [cited 2020 Oct 23];7:313-7. Available from: http://www.roaic.eg.net/text.asp?2020/7/3/313/296616

  Background Top

Coronary ostial stenosis is a rare but fatal consequence of aortic root surgery. Clinical manifestations include myocardial infarction, ventricular arrhythmias, hemodynamic instability, or sudden death. Three interesting cases of iatrogenic acute coronary ostial stenosis after Bentall’s procedure will be presented, with each case having a different outcome. There will also be a brief discussion of the management for this complication.

  Cases presentation Top

Case 1

A 56-year-old male patient, with chronic systemic hypertension and paroxysmal atrial fibrillation, was admitted for elective Bentall’s procedure. The ethical committee of King Faisal Specialist Hospital and Research Center exempted this publication from a specific consent as it does not reveal any identifiable private information of studied patients. Preoperative echocardiography showed dilated left ventricle with ejection fraction 30–35%, severely dilated aortic root with severe aortic regurgitation, and moderate mitral regurgitation, while the right ventricle function was moderately reduced with trace tricuspid regurgitation. Coronary angiogram showed insignificant coronary artery disease. Modified Bentall’s procedure with button technique was performed with an aortic clamping time of 155 min and perfusion time [cardiopulmonary bypass (CPB)] of 200 min. After 8 hours, the patient developed ventricular fibrillation and received three defibrillation shocks. ECG showed inferior STEMI. Emergency coronary angiography was performed via the femoral approach. Aspiration catheter was used to aspirate right coronary artery ostial thrombus followed by predilatation of the ostial lesion and then stenting using a drug-eluting stent 4.0×23 mm with successful TIMI flow III and without residual lesion. The patient received loading doses of aspirin and clopidogrel with heparin intravenous infusion. Intra-aortic balloon pump was used for maintaining the hemodynamics. The fluoroscopy excluded mechanical valve dysfunction. After 5 days, the patient was transferred to the ward and then discharged home on dual antiplatelets and warfarin with stable cardiac condition ([Figure 1]).
Figure 1 Case 1 showing right coronary artery with ostial thrombotic occlusion and then after thrombus aspiration and DES deployment and expansion.

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Case 2

A 39-year-old female patient was admitted with severe aortic regurgitation and aneurysmal dilatation of the ascending aorta. Modified Bentall’s procedure with button technique was performed. After decannulation and hemostasis, sudden hemodynamic collapse occurred with ventricular fibrillation. After resuscitation, central venoarterial extracorporeal membrane oxygenation (VA-ECMO) was inserted. The total CPB was 368 min while the aortic clamping time was 249 min and circulatory arrest time was 43 min. Emergency angiography was done via the femoral approach and showed left main ostial 90% stenosis. Balloon dilatation and stenting were performed using a drug-eluting stent 4×12 mm with successful TIMI flow III and without residual lesion. The patient received loading doses of aspirin and clopidogrel with heparin infusion, but the patient developed mediastinal bleeding necessitating re-exploration and temporary stoppage of antiplatelets and anticoagulant therapy. The patient developed a complicated ICU course with ventilator-associated pneumonia and left upper limb deep venous thrombosis, but gradual improvement occurred with cardiovascular and ventilatory weaning. The patient was discharged after 75 ICU days with left ventricular dysfunction and ejection fraction 40–45% ([Figure 2]).
Figure 2 Case 2 showing ostial left main stenosis (left image) and after stenting (right image).

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Case 3

A 41-year-old woman who underwent mitral and aortic valve replacement with bioprosthetic valves 12 years ago, was admitted with progressive heart failure and echocardiography showed two valves degenerated with severe regurgitation. Coronary angiography showed normal coronary arteries. After the third redo sternotomy, mitral valve replacement, and modified Bentall’s procedure with button technique were performed. The surgery was complicated with ventricular arrhythmia before chest closure requiring resuscitation and going back on pump with exploration of the aortic root. The operation was terminated with VA ECMO. The CPB time was 198 min and the aortic clamping time was 169 min. Urgent transesophageal echocardiography (TEE) showed severe reduction of left ventricular contractility with extensive regional wall motion abnormalities. ECG showed anterior STEMI and emergency coronary angiography showed left main ostial significant stenosis. The patient was transferred back to the operation room for urgent coronary artery bypass graft (CABG). Heparin infusion and aspirin were maintained but follow-up echocardiography showed reduced left ventricular contractility with large mural thrombus. After 8 days of surgical procedure, the patient developed massive stroke with brain stem death and cardiac arrest ([Figure 3]).
Figure 3 Case 3 showing left main ostial abrupt occlusion.

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  Discussion Top

In 1968, Bentall and De Bono described a surgical procedure of composite mechanical aortic valve conduit replacement for an aortic root aneurysm with direct reimplantation of the coronary arteries [1]. However, many modifications from the original technique have been proposed to prevent postoperative bleeding, minimize the tension at the site of coronary reimplantation, and to prevent pseudoaneurysm formation [2],[3],[4].

Currently, the modified Bentall techniques that involve coronary button reimplantation have become the procedure of choice in many cardiothoracic centers around the world with good results [5],[6],[7],[8].

Coronary ostial stenosis was described as a possible late complication of the aortic surgical procedures [9]. It was prescribed as a life-threatening complication after 6 months in 1–5% of aortic valve replacement operations. Several mechanisms were thought to be involved including the possibility of microinjuries and local hyperplastic reaction related to the pressure of infusion and/or low temperature of cardioplegic solution and overdilation of the coronary arteries by cardioplegic catheters [9],[10].

An immunological reaction to the heterograft after aortic root surgery has been considered in few cases of bilateral stenosis of coronary ostia several months following the surgical procedure [9],[11].

Few case reports described the occurrence of acute coronary ostial stenosis. Right coronary artery ostial occlusion from aortotomy sutures and ostial post-traumatic thrombosis due to aortic retractor have been described [11]. In other cases, embolism from the debris, more often calcium related to aortic valve decalcification or left atrial thrombectomy can be involved [11],[12],[13]. Coronary artery spasm has been described as a potential cause of hemodynamic instability and arrhythmias after aortic valve replacement [14]. Occasionally, secondary fibrosis in the area of suture placement may occur causing ostial stenosis [15]. Finally, the use of surgical glue in aortic root surgery, or compression from outside due to the glue used to protect the anastomosis may cause stenosis of one or both coronary ostia [16]. Turillazzi et al. [17] have described a case of extensive myocardial infarction due to intraoperative occlusion of both coronary ostia by the aortic prosthetic valve.

Trans-esophageal echocardiography was useful in the diagnosis of acute myocardial ischemia by the detection of regional wall motion abnormalities and exclusion of acute valvular dysfunction as an explanation to the hemodynamic deterioration. TEE had a role in guiding management and transfer to catheterization laboratory. Early support with VA-ECMO was effective in managing patients with refractory ventricular arrhythmia and hemodynamic instability. VA-ECMO was successful in supporting the patients till achieving revascularization either by percutaneous coronary intervention or CABG. VA-ECMO allows for both respiratory and circulatory support and was approved for use after failed weaning from cardiopulmonary bypass. Early recognition of clinical deterioration and initiation of VA ECMO in appropriate candidates increased the chance for survival [18],[19].

Emergency coronary angiography was effective in both diagnosis and management. It was tolerated well in the three cases and reached the causes of hemodynamic deterioration. Percutaneous coronary intervention and stenting were successfully done in two cases and the patients survived and discharged while the third patient who underwent urgent CABG suffered from massive bleeding and cerebrovascular stroke and died.

Stenting was done using drug-eluting stents and dual antiplatelet therapy was started without significant postoperative bleeding.

Conclusively, acute coronary ostial stenosis may occur after aortic root surgery and this complication may be life threatening and may lead to myocardial infarction or fatal ventricular arrhythmia. Consequently, it is important to have a high index of suspicion if circulatory collapse and/or signs of myocardial ischemia occur soon after aortic surgery. Emergency coronary angiography helps in the diagnosis and management after Bentall’s coronary disruption.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax 1968; 23:338–339.  Back to cited text no. 1
Cabrol C, Pavie A, Gandjbakhch I et al. Complete replacement of the ascending aorta with reimplantation of the coronary arteries: new surgical approach. J Thorac Cardiovasc Surg 1981; 81:309–315.  Back to cited text no. 2
Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Composite valve graft replacement of the proximal aorta: comparison of techniques in 348 patients. Ann Thorac Surg 1992; 54:427–439.  Back to cited text no. 3
Kourliouros A, Soni M, Rasoli S, Grapsa J, Nihoyannopoulos P, O’Regan D et al. Evolution and current applications of the Cabrol procedure and its modifications. Ann Thorac Surg 2011; 91:1636–1641.  Back to cited text no. 4
Coselli JS, Crawford ES. Composite valve-graft replacement of aortic root using separate Dacron tube for coronary artery reattachment. Ann Thorac Surg 1989; 47:558–565.  Back to cited text no. 5
Guilmet D, Bonnet N, Saal JP, Le Houerou D, Ghorayeb G. Long term survival with the Bentall button operation in 150 patients [Article in French]. Arch Mal Coeur Vaiss 2004; 97:83–91.  Back to cited text no. 6
Kouchoukos NT, Marshall WG Jr, Wedige-Stecher TA. Eleven-year experience with composite graft replacement of the ascending aorta and aortic valve. J Thorac Cardiovasc Surg 1986; 92:691–705.  Back to cited text no. 7
Westaby S, Katsumata T, Vaccari G. Aortic root replacement with coronary button re-implantation: low risk and predictable outcome. Eur J Cardiothorac Surg 2000; 17:259–265.  Back to cited text no. 8
Yates JD, Kirsh MM, Sodeman TM et al. Coronary ostial stenosis: a complication of aortic valve replacement. Circulation 1974; 49:530–534.  Back to cited text no. 9
Ziakas AG, Economou FI, Charokopos NA et al. Coronary ostial stenosis after aortic valve replacement: successful treatment of 2 patients with drug-eluting stents. Texas Heart Inst J 2010; 37:465–468.  Back to cited text no. 10
Pillai JB, Pillay TM, Ahmad J. Coronary ostial stenosis after aortic valve replacement, revisited. Ann Thorac Surg 2004; 78:2169–2171.  Back to cited text no. 11
Santini F, Pentiricci S, Messina A, Mazzucco A. Coronary ostial enlargement to prevent stenosis after prosthetic aortic valve replacement. Ann Thorac Surg 2004; 77:1854–1856.  Back to cited text no. 12
Thomopoulou S, Sfirakis P, Spargias K. Angioplasty, stenting and thrombectomy to correct left main coronary stem obstruction by a bioprosthetic aortic valve. J Invasive Cardiol 2008; 20:124–125.  Back to cited text no. 13
Pragliola C, Altamura L, Niccoli G et al. Postoperative coronary artery spasm complicating aortic valve replacement: implications for identification and treatment. Ann Thorac Surg 2007; 83: 670–672.  Back to cited text no. 14
Sethi GK, Scott SM, Takaro T. Iatrogenic coronary artery stenosis following aortic valve replacement. J Thorac Cardiovasc Surg 1979; 77:760–767.  Back to cited text no. 15
Marino M, Cellini C, Tsiopoulos V et al. A case of myocardial infarction effectively treated by emergency coronary stenting soon after a Bentall-De Bono aortic surgery. Cardiovasc Revasc Med 2010; 11:263.e5–263.e9.  Back to cited text no. 16
Turillazzi E, Giammarco GD, Neri M et al. Coronary ostia obstruction after replacement of aortic valve prosthesis. Diagn Pathol 2011; 6:72.  Back to cited text no. 17
Abrams D, Combes A, Brodie D et al. Extracorporeal membrane oxygenation in cardiopulmonary disease in adults. J Am Coll Cardiol 2014; 63:2769–2778.  Back to cited text no. 18
Takayama H et al. Clinical outcome of mechanical circulatory support for refractory cardiogenic shock in the current era. J Heart Lung Transplant 2013; 32:106–111.  Back to cited text no. 19


  [Figure 1], [Figure 2], [Figure 3]


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