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Interact CardioVasc Thorac Surg 2007;6:511-513. doi:10.1510/icvts.2006.146191 © 2007 European Association of Cardio-Thoracic Surgery
Ostial stenosis after Bentall technique using glue: percutaneous stenting may be ineffective Cardiovascular Institute of Buenos Aires, Blanco Encalada 1543, (1428) Buenos Aires, Argentina Received 24 October 2006; received in revised form 27 March 2007; accepted 28 March 2007
Background: Hemorrahage after coronary re-implantation during a Bentall surgery is a rare complication. In case of friable tissue, the use of a felt disc usually solves the problem. The use of resorcinol-formol-glue should be avoided to prevent tissue damage. Extrinsic compression of the coronary arteries has been reported with the use of this surgical glue. Case: We report a rare case of extrinsic compression of both coronary arteries after a Bentall procedure. A 50-year-old man with severe aortic valve stenosis, without coronary disease and an ascending aortic aneurysm, underwent a modified Bentall procedure with insertion of a valved tube and coronary re-implantation using surgical glue. Seven weeks later he suffered severe acute coronary ischemia and both coronary ostium were compressed by a dense and hard fibrose material. Three months after stenting, the patient required coronary surgery because of severe myocardial ischemia. Transesophageal and intracoronary ultrasounds were useful for the diagnosis of this rare complication. Conclusions: Use of glue should be avoided for coronary reimplantation during Bentall surgery. In cases of external ostial compression by glue reaction, stenting may be ineffective and surgical coronary revascularization may be needed.
Key Words: Bentall procedure; Aneurysm; Aorta; Coronary angiography; Angioplasty; Transesophageal echocardiography
A 50-year-old man with a history of severe aortic valve stenosis and a 45-mm diameter ascending aortic aneurysm underwent a modified Bentall–de Bono procedure with insertion of a valved tube prosthesis (St. Jude #23, St. Jude Medical, Minneapolis, MN, USA). Coronary re-implantation was performed using direct suture with 5/0 prolene and a felt disc due to friable and calcified tissue. Gelatin-resorcinol-glue (GRF, Cardial, Saint Etienne, France) was used to minimize the bleeding of the ostias. Preoperative cardiac catheterization showed no signs of obstructive coronary artery disease (Fig. 1a).
Seven weeks later, the patient was readmitted due to a sudden onset of resting angina associated with diffuse ST-depression and severe heart failure. Coronary angiography revealed severe left main (LM) and moderate proximal right coronary artery (RCA) stenosis (Fig. 1b). Successful LM bare metal stent implantation was performed with the adjunctive use of intra-aortic balloon counterpulsation. Transesophageal echocardiogram showed a nodular structure surrounding the posterior aspect of the aortic root (Fig. 2a). After 10 days, the patient was discharged under triple antithrombotic treatment: aspirin, coumadin and clopidogrel).
Three months after surgery (one month after stenting), coronary angiogram showed mild left main stenosis at the stent site whereas no significant obstruction was observed at the proximal RCA site. LM intravascular ultrasound showed a hipoechoic mass prolapsing through the stent struts with no signs of intra-stent neointima formation (Fig. 2b). Six months after surgery, widespread myocardial ischemia was documented by non-invasive nuclear perfusion imaging. A repeated coronary angiogram showed severe diffuse LM intra-stent restenosis, as well as severe proximal RCA stenosis (Fig. 1c). Due to the significant amount of myocardial ischemia, the patient underwent off-pump coronary artery bypass surgery (OPCAB) with bilateral internal mammary artery anastomosis. During surgery, a dense and hard fibrose material was found surrounding the aortic root. The patient remains symptom-free at twenty-four month follow-up OPCAB.
Coronary artery re-implantation during a Bentall procedure has been associated with hemorrhage, particularly due to arterial leakage. In order to treat this complication, surgical glue is occasionally used [1], but several complications have been described [2–4]. Among them, extrinsic compression of the coronary arteries has been reported with the use of this surgical glue [5–7]. This uncommon complication appears to be related to an abnormal patient reactivity to GRF glue. Transesophageal echocardiogram was found to be a useful diagnostic tool in this rare complication. Ostial coronary stenosis may cause an acute coronary syndrome [8]. Surgical or percutaneous revascularization may be required early after aortic surgery. Coronary angioplasty is an attractive approach in these complex postoperative patients [9, 10]. However, in our case, both techniques were performed because of extrinsic ‘restenosis’ of percutaneous angioplasty. Percutaneous revascularization was ineffective in our patient because a hard fibrose tissue collapsed the stent, shown by intracoronary ultrasound. These uncommon complications must be discussed in a patient with signs of acute coronary ischemia early after a Bentall procedure. Percutaneous revascularization may be ineffective and surgical revascularization may be needed. We do not recommend the use of glue for coronary artery re-implantation during a Bentall operation.
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Abstract
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