Download ST Segment Elevation Myocardial Infarction following Valve

ST Segment Elevation Myocardial
Infarction following Valve
Replacement Surgery:
An Unusual Presentation
Venkataramanan Gangadharan, MD
Shafeeq Ahmed, MD
Brian Zagol, MD
George Vetrovec, MD
Case Presentation
• 35 year old man with history of HIV presented with
fever and chills to an outside hospital
• Patient was found to be bacteremic and subsequent
TEE revealed infective endocarditis with a large
vegetation on the mitral valve severe mitral
regurgitaton.
• Pre-operative cardiac catheterization revealed an
anomalous left coronary artery from the right Sinus of
Valsalva but no obstructive coronary artery disease.
Pre-Operative Coronary Angiogram
Case Presentation
• Patient underwent a successful pericardial tissue valve
replacement with a 29 mm Edwards mitral valve
through an open sternotomy.
• 24 hours post procedure the patient began experience
severe chest pain and diagnosed with an ACUTE Lateral
ST Segment Elevation with troponin peaking at 30.
ECG
Coronary Angiogram
LAO Caudal showing no new
disease in the left coronary system
Occluded Anomalous Left Circumflex from
Right Sinus of Valsalva
Coronary Intervention
Balloon Angioplasty to the
occluded Left Circumflex
No significant
improvement to flow post
balloon angioplasty
Contrast injection through
balloon
Coronary Intervention
Post 3.0 x 12 mm INTEGRITY
bare metal stent placement
Post overlapping 2.75 x 12 mm
INTEGRITY bare metal stent placement
Discussion
• Ischemic iatrogenic coronary lesions can complicate
mitral valve surgery - either valve replacement or
annuloplasty
• Commonly affected vessels include the left circumflex
or posterior descending artery due to their proximity to
the mitral valve
• Risk of ischemic insults usually depend on anatomic
relationships between the coronary artery and
posterior mitral annulus – rarely further complicated in
patients with anomalous coronary origins.
Discussion
• Coronary Injury post mitral valve replacement is a
known complication although the mechanism of injury
has been sparingly identified through isolated case
reports.
• Injury can be divided into those due to direct
mechanical compression/distortion of the vessel,
coronary artery embolization (air embolization, silcone
material embolization or suture material), or injury to
the coronary endothelium caused by ablative
procedures (MAZE) done in conjunction with surgery.
• Clinically patients can present intra-operatively or in
the post-operative period with typical manifestations
Discussion
• Intra-operative - recurrent ventricular arrhythmias,
subtle but new wall motion abnormalities or even STelevation on cardiac monitoring can indicate vessel
compromise
– Rapid treatment can be achieved performing emergency
saphenous vein graft bypass to the compromised vessel.
• Post-operative – patient can present with typical
symptoms, persistent ventricular arrhythmias, ST
Elevation and even sudden hemodynamic compromise
– Treatment can be achieved percutaneously with
intervention to the culprit vessel.
Conclusion
• Potential risk of iatrogenic coronary artery injury does
exist with mitral valve surgery
• Percutaenous and surgical options are available for
treatment and valve integrity should be evaluated in
cases secondary to mechanical compression.
• Appropriate pre-operative visualization of the coronary
circulation especially with regards to anatomy and
course can help to avoid such complications during
surgery.
References
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