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A 63-year-old man underwent an aortic valve replacement (Carbomedics Top Hat No 23) for a severe aortic stenosis. A tricuspid annuloplasty and closure of an ostium secundum atrial septal defect were also performed. The preoperative electrocardiogram showed a left bundle branch block. There were no significant alterations in the coronary angiogram. A dominant right coronary artery was seen. While the patient was coming off the pump he presented severe haemodynamic instability and diffuse ST segment alterations (panel A). Transoesophageal echocardiography showed severe right ventricular dysfunction. Systolic blood pressure with inotropic drugs was 65 mm Hg. The angiogram showed luminal narrowing of the ostium of the right coronary artery (arrow) with aortic wall deformation (panel B) and a double-border spot (panel C) on the aortic wall. These abnormalities were ascribed to the indentation caused by a periprosthetic intramural haematoma. No flap was detected in the aortography. To widen the coronary lumen and to avoid progression of the haematoma, which might lead to potential occlusion of the ostium, a non-drug-eluting stent with a diameter of 4.0 mm and length of 15 mm was implanted. The blood pressure and electrocardiographic changes improved (panel D) after stent implantation and the patient was successfully extubated 8 hours later.
This article has been adapted from Marti V, Paniagua P, Ginel A. Severe coronary luminal narrowing ascribed to aortic intramural haematoma after valve surgery Heart 2007;93:1405
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