P709 Rare complication of delayed iatrogenic critical left main coronary (LMC) occlusion after a re-do aortic valve replacement (AVR) post an acute prosthetic valve intrinsic dysfunction in a young patient
Authors: Fady G , Komaranchath A M , Al Bakshy F B , Kakani M K 
Published: January 2020

Abstract

Funding Acknowledgements
Nil
Introduction
Delayed LMC obstruction is quite a rare but fatal complication of surgical AVR. It is iatrogenic however can be induced by embolization of aortic calcium plaque or surgical over-tightening of the new aortic valve suture ring over the LMC ostium during surgery
Case report
Herein, we report a case of LMC severe ostial obstruction that occurred 30 days post a re-do surgical AVR for a young 38-year-old male young patient.
The patient presented with palpitations, dyspnea NYHA class III and general fatigue started 4 weeks earlier.
Diagnosed by 2D transthoracic echo (TTE) as bicuspid aortic valve (BAV) with severe aortic regurgitation (AR), grade II-III mitral regurgitation (MR) and severe pulmonary hypertension with estimated LV ejection fraction (LVEF) of 40%. Transesophageal echo (TEE) confirmed the same however demonstrated the MR grade as severe.
Hence posted for a double valve replacement (DVR) surgery. Preoperative coronary angiography (CAG) revealed normal coronaries.
Intraoperative TEE showed well-functioning both prostheses.
On day 5 postoperatively patient developed dyspnea, orthopnea and was restless.
Bed side 2D echo both revealed severe eccentric AR with query one stuck disc of the AV prosthesis in the setting of acute severe LV dysfunction with LVEF of 20%.
Cinefluoroscopy confirmed our diagnosis of one stuck disc in an opened position. We attempted to mobilize the disc using a 0.035 wire through the aorta, however, this proved unsuccessful. So, we scheduled the patient for an urgent redo AVR.
Intraoperative inspection of the resected prosthesis ruled out thrombosis and revealed that the disc was immobile secondary to a manufacturing intrinsic defect.
Intraoperative TEE confirmed a successful redo AVR with normal new prosthesis function.
Patient made a steady recovery and was discharged 7 days later. Screening TTE before discharge showed improved LVEF from 20% to 35%.
Patient presented 30 days later with new onset classic angina on effort.
Our greatest fear of a complicated delayed iatrogenic critical LMC occlusion was proven on CAG that showed a discrete 90% stenosis of ostial LMC artery.
we underwent an intravascular ultrasound (IVUS)- guided successful percutaneous coronary intervention to ostial LMC artery after which patient recovered very well.
TTE before discharge showed further improvement of LVEF to 50%. He was followed up for two years later with no complications neither any symptoms.
Conclusions
Although a very rare complication, however endogenous intrinsic defect of the prosthetic valve might be fatal with acute decompensation and complications that merit immediate action.
With the help of multimodal imaging we were able to timely diagnosis and illustrate the cause and extent of acute prosthesis dysfunction.
It is very important to have a high diagnostic suspicion if signs of myocardial ischemia occur after surgical AVR even if delayed as occurred in our patient.
Abstract P709 Figure. Severe AR-Prosthesis dysfunction-LM obst