Right coronary artery stenosis associated with tricuspid valve ring annuloplasty
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CASE REPORT
Right coronary artery stenosis associated with tricuspid valve ring annuloplasty Keiichi Tsuchida1 • Kota Nishida1 • Hirotaka Oda1 • Yukio Hosaka1 Kazuyoshi Takahashi1 • Satoshi Nakazawa2
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Received: 1 October 2016 / Accepted: 8 December 2016 Ó Japanese Association of Cardiovascular Intervention and Therapeutics 2016
Abstract A 70-year-old man with severe symptomatic functional mitral valve regurgitation underwent successful mitral valve repair combined with tricuspid valve ring annuloplasty. Pre-operative coronary angiography (CAG) showed no significant stenosis. One-and-a-half years later, the patient presented with an acute exacerbation of heart failure. Repeat CAG demonstrated tight stenosis in the right coronary artery (RCA) with arterial kinking that corresponded to the same point as the stenosis where the RCA is the closest to the tricuspid valve ring. The new lesion probably occurred as a consequence of the tricuspid valve ring annuloplasty. Keywords Tricuspid annuloplasty Right coronary artery injury Perioperative myocardial infarction
Case report A 70-year-old man with severe symptomatic functional mitral valve regurgitation and poor functional class (NYHA III/IV) was referred for surgical valve replacement. His electrocardiogram showed atrial fibrillation that was assumed to be permanent. An echocardiogram demonstrated preserved left ventricular (LV) function accompanied with severe right ventricular (RV) dilatation. Pre-operative coronary angiography (CAG) for screening showed normal & Keiichi Tsuchida [email protected] 1
Department of Cardiology, Niigata City General Hospital, Shumoku 463-7, Chuo-ku, Niigata 950-1197, Japan
2
Department of Cardiovascular Surgery, Niigata City General Hospital, Niigata, Japan
appearing coronary arteries (Fig. 1). He underwent successful mitral valve repair combined with tricuspid valve (TV) annuloplasty using a 34-mm flexible annuloplasty ring (MC [3], Edwards Lifesciences, Irvine, CA). Creatine kinase (CK)/CK-MB was elevated to 2367/219 IU/l on post-operative day 1, though the CK/CK-MB rise was attributed to an esophageal injury associated with perioperative transesophageal echocardiographic examinations. The post-operative course was otherwise uncomplicated except for the use of low-dose inotropes for a week after surgery. The patient was discharged 23 days after surgery on furosemide 40 mg. However, his physical activity was limited with fatigue caused by ordinary activity. One-and-a-half years later, the patient presented with an acute exacerbation of heart failure (HF) and was admitted to our department. New inferior small Q waves (II, III, and aVF) were noticed on the admission electrocardiogram (ECG) and inferior ST-segment elevation on the 9-day post-operative ECG was recognized retrospectively (Fig. 2). Echocardiography showed severe hypokinesis of the inferior LV wall, which was normal pre-operatively, and moderate-to-severe recurrent mitral regurgitation. CAG was repeated and demonstrated a tight stenosis with TIMI grade 1 flow
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