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 Table of Contents  
LETTER TO THE EDITOR
Year : 2016  |  Volume : 4  |  Issue : 4  |  Page : 156-157

Acute dilatation of right ventricle following aortic valve replacement


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 Publication20-Dec-2016

Correspondence Address:
Vivek Chowdhry
Department of Cardiac Anaesthesiology, CARE Hospital, Chandrasekharpur, Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-449x.196283

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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

How to cite this URL:
Chowdhry V, Suvakanta B, Mohanty B B. Acute dilatation of right ventricle following aortic valve replacement. Heart India [serial online] 2016 [cited 2021 Dec 2];4:156-7. Available from: https://www.heartindia.net/text.asp?2016/4/4/156/196283

Sir,

Coronary artery obstruction after valve surgery is a rare entity with a reported incidence of about 0.3%–5%.[1] 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.[2] 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.
Figure1:(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.
Figure2: 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.[3] 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.[4],[5]

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Umran S, Chetty G, Sarkar PK. Acute right coronary ostial stenosis during aortic valve replacement. Int J Prev Med 2012;3:295-7.  Back to cited text no. 1
    
2.
Ziakas AG, Economou FI, Charokopos NA, Pitsis AA, Parharidou DG, Papadopoulos TI, et al. Coronary ostial stenosis after aortic valve replacement: Successful treatment of 2 patients with drug-eluting stents. Tex Heart Inst J 2010;37:465-8.  Back to cited text no. 2
    
3.
Roberts WC, Morrow AG. Late postoperative pathological findings after cardiac valve replacement. Circulation 1967;35 4 Suppl:I48-62.  Back to cited text no. 3
    
4.
Turillazzi E, Di Giammarco G, Neri M, Bello S, Riezzo I, Fineschi V. Coronary ostia obstruction after replacement of aortic valve prosthesis. Diagn Pathol 2011;6:72.  Back to cited text no. 4
    
5.
Funada A, Mizuno S, Ohsato K, Murakami T, Moriuchi I, Misawa K, et al. Three cases of iatrogenic coronary ostial stenosis after aortic valve replacement. Circ J 2006;70:1312-7.  Back to cited text no. 5
    


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