Subacute left main trunk occlusion following surgical aortic valve replacement

Coronary artery occlusion is a rare but potentially fatal complication after surgical aortic valve replacement (SAVR), and subacute left main trunk (LMT) occlusion after SAVR has not been reported. A 70-year-old woman was diagnosed with severe aortic valve stenosis caused by a bicuspid valve. SAVR with a supra-annular EPIC valve (19 mm; Abbott, Abbott Park, IL, USA) placement was performed. The patient developed acute dyspnea and cardiogenic shock on postoperative day 6. Coronary computed tomography (CT) revealed LMT occlusion with extensive severe subendocardial ischemia. Emergent percutaneous coronary intervention was performed, revealing a thrombus in the LMT and a hyperechoic structure near the LMT entrance on intravascular ultrasonography. After thrombus aspiration and laser atherectomy, a drug-eluting stent protruding into the aorta was deployed. The patient was discharged from the hospital on day 39 after heart failure compensation. CT performed 3 months after discharge revealed the proximity of the support structure of the EPIC valve to the LMT, without significant stenosis. This case report suggests some potential etiologies of subacute coronary artery occlusion after SAVR.

Learning objective

Subacute left main trunk (LMT) occlusion rarely occurs after surgical aortic valve replacement (SAVR). Although it is difficult to explain this phenomenon using a single etiology, we hypothesized that an unrecognized injury during coronary cannulation or the proximity of the support structure of the EPIC valve to LMT entrance could be potential etiologies contributing to endothelial damage and subsequent thrombus formation. This case highlights that coronary obstruction, as a complication following SAVR, can occur at various time points.