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Eur J Cardiothorac Surg 2003;23:651-652
© 2003 Elsevier Science NL
Letter to the Editor |
Regional Cardiac Centre, Morriston Hospital, Morriston, Swansea, SA6 6NL, UK
Received 13 November 2002; accepted 17 December 2002.
* Corresponding author. 39 Park Drive Skewen, Neath, West Glamorgan, SA10 6SG, UK. Tel.: +44-1792-814849; fax: +44-1792-703242
e-mail: rammohankandadai{at}hotmail.com
Key Words: Ostial stenosis • Aortic valve • Indwelling cannula
The excellent image that was printed in the July 2002 issue of the EJCTS by Zamvar et al. [1] was a graphic illustration of the potentially serious complication of ostial stenosis following coronary cannulation during aortic valve replacement.
Having experienced two similar complications in the last 2 years, we decided to retrospectively review our experience with two methods of coronary cannulation-hand held cannulation and indwelling cannulae. The aim was to attempt to establish a causal relationship for this phenomenon. As a prelude to that, we would like to briefly summarize our experience with coronary ostial stenosis following aortic valve replacement with coronary cannulation using the Polystan® Cannula.
From October 1997 to June 2002, 233 isolated aortic valve replacements have been done in our Regional Cardiac Centre. Two patients (0.8%) developed ostial coronary artery stenosis following their valve replacements.
The first gentleman was 63 years old and had a mechanical aortic valve replacement in October 2000. He developed severe angina by January 2001 and had a positive exercise test. He went onto have an angiogram whilst continuing to have ST changes at rest. The angiogram revealed severe left main stem disease in a dominant left system. He was operated on as an emergency later the same day and made an uneventful recovery.
The second patient was a 66-year old lady who had a bioprosthetic aortic valve inserted in February 2001. She developed severe anginal symptoms within 6 weeks and was restricted in her activity. She was investigated further and had an angiogram in January 2002 which showed significant ostial stenoses in the right and left systems. She was clinically stable but severely restricted in her activities. She had coronary artery bypass grafting (CABG) in May 2002 and made an uneventful recovery.
Both the patients had their valves inserted in an identical fashion using interrupted radial Ethibond sutures (by the same surgeon). Antegrade cold blood cardioplegia, initially and intermittent coronary perfusion were used for myocardial protection. The ostia were cannulated using indwelling Polystan® Balloon Tipped Soft Coronary Cannula-angled and straight. Cardiopelgia was administered at 10–15 min intervals during the valve insertion.
Ostial stenosis following coronary cannulation is a potentially life threatening complication that requires to be treated in an emergent manner. The hypotheses put forward for this phenomenon include local pressure necrosis produced by the indwelling perfusion catheters, a genetic predisposition and turbulent flow across the valve causing intense fibrosis [2–5]. However, the exact cause of this rare but critical condition remains undetermined.
References
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