Coronary ostia obstruction after replacement of aortic valve prostesis

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/4383994185667026 webcite.Aortic valve replacement (AVR) remains the gold standard for the treatment of severe symptomatic aortic stenosis. Late coronary ostial stenosis is described as late complication of the surgical procedure [1]. Anecdotal reports concern coronary ostial stenosis as acute complication: right ostial occlusion from aortotomy suture, ostial thrombosis as traumatic consequence from an aortic retractor, coronary artery spasm, calcium debris embolization and partial direct occlusion by the device or edematous reaction have been described [2-4].A unique fatal case of intraoperative, bilateral coronary ostial obstruction by prosthetic valve leading to myocardial infarction is reported.A 50 -year old woman, previously submitted to surgical aortic valve replacement in 2003 for aortic valve stenosis was admitted to a cardiac surgery unit for replacement of dysfunctioning mechanical valve prosthesis. Echocardiographic evaluation documented a prosthetic dysfunction with the evidence of an increased peak gradient up to 105 mmHg and a prosthetic valve area by 0.58 cm2 in a normal left ventricular function. Prosthetic valve replacement was then performed in August 2010. Cardiopulmonary bypass (CPB) was instituted between right atrium and ascending aorta and a moderate hypothermia was reached. Myocardial protection was achieved by retrograde injection of blood cardioplegia through coronary sinus as induction; it was completed by antegrade injection directly in both coronary ostia. After ascending aorta had been transversely opened, prosthetic dysfunction was evident as one of the hemidisks appeared to be locked by pannus ingrowth and fresh pivotal thrombi. No perivalvular leaks were described. The prosthesis was then removed; both coronary ostia were described quite close to the aortic annulus. Bovine pericardium bioprosthesis (Edwards Magna Ease 21 mm) was the