|LETTER TO THE EDITOR
|Year : 2016 | Volume
| Issue : 4 | Page : 156-157
Acute dilatation of right ventricle following aortic valve replacement
Vivek Chowdhry1, Biswal Suvakanta2, BB Mohanty2
1 Department of Cardiac Anaesthesiology, CARE Hospital, Bhubaneswar, Odisha, India
2 Department of Cardiothoracic and Vascular Surgery, CARE Hospital, Bhubaneswar, Odisha, India
|Date of Web Publication||20-Dec-2016|
Department of Cardiac Anaesthesiology, CARE Hospital, Chandrasekharpur, Bhubaneswar, Odisha
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Chowdhry V, Suvakanta B, Mohanty B B. Acute dilatation of right ventricle following aortic valve replacement. Heart India 2016;4:156-7
Coronary artery obstruction after valve surgery is a rare entity with a reported incidence of about 0.3%–5%. Iatrogenic intraoperative acute coronary artery obstruction is potentially a fatal complication of valve surgery. It can manifest immediately in the intraoperative period or can be delayed by days or months. Here, we describe a case of intraoperative acute right ventricular (RV) dilatation with poor contractility after aortic valve replacement (AVR) which was relieved dramatically by bypass grafting of right coronary artery (RCA).
A 61-year-old female with severe aortic stenosis was admitted for AVR. The transthoracic echocardiogram revealed a severely calcified bicuspid aortic valve, peak aortic gradient of 98.6 mmHg, mean gradient of 63 mmHg, concentric left ventricular hypertrophy with ejection fraction of 66%, and normal RV function. Coronary angiogram revealed normal coronaries with left dominant circulation and small RCA [Figure 1]a and [Figure 1]b.
|Figure 1: (a) Coronary angiogram showing left dominant circulation. (b) Coronary angiogram showing nondominant right coronary artery|
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In intraoperative transesophageal echocardiography, aortic valve was found to be heavily calcified with moderate annular calcification. A transverse aortotomy was performed; the valve was excised, and after decalcification of the annulus, a 21-mm Trifecta (St. Jude Medical, Inc., St. Paul, MN, USA) bioprosthesis was implanted.
During coming off bypass, the patient had complete heart block and RV was noticed to be distended. The pacing was started at a rate of 80/min. As the blood pressure was normal with good LV systolic function and soft pulmonary artery, the cardiopulmonary bypass (CPB) was discontinued. However, RV still seemed to be distended and poorly contractile; transesophageal echocardiogram revealed dilated right-sided chambers and severe tricuspid regurgitation with peak gradient of 16 mmHg along with bulging of the interatrial septum into the left atrium [Figure 2]. A full bypass was reinstated with increase in perfusion pressure, and the heart was rested. On the second attempt at weaning from bypass, despite increasing inotropic supports, the RV systolic function remained poor.
|Figure 2: Transesophageal echocardiographic view showing dilated right atrium and right ventricle with bulging of interatrial septum into the left atrium|
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Suspecting coronary obstruction causing severe RV dysfunction, the mid-RCA was opened on CPB with a beating heart to reveal no flow in the artery. A coronary artery bypass to the mid-RCA was performed. After revascularization, the RV contractility improved, and after a short period of pacing, the sinus rhythm resumed. On discontinuation of CPB, a normal contracting RV was apparent without further distension. Rest of the postoperative course was uneventful, and echocardiogram on the 2nd postoperative day revealed good biventricular systolic function with normally functioning aortic bioprosthesis.
Roberts and Morrow, in 1967, first described the coronary artery obstruction after AVR by postmortem histological analysis. Delayed coronary obstruction after valve surgery can cause postoperative angina and arrhythmias. It can be fatal, and thus, timely recognition and management is essential for patient's safety. Traumatic insertion of ostial cardioplegia cannula may cause intimal thickening and fibrosis leading to delayed coronary stenosis; however, iatrogenic coronary ostial dissection, embolism of calcium or fat globules, or iatrogenic occlusion of coronary ostia by prosthetic valve can cause acute intraoperative instability.,
In conclusion, we suspect that coronary ostial dissection or embolism of calcium particles might have caused acute occlusion of the RCA leading to intraoperative RV dysfunction with hemodynamic instability and difficulty in weaning from bypass. However, acute occlusion of such a small and nondominant RCA leading to acute RV dysfunction and complete heart block has never been reported. Here, we recommend that, in case of acute RV dysfunction after manipulation of calcific aortic valve, one must primarily suspect coronary obstruction which should be promptly recognized and revascularized for the safe outcome.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]