Multimodal approach to assess a circumflex artery extrinsic stenosis after five years of mitral plasty
Salinas-Casanova, José A; Ibarrola-Peña, Juan Carlos; Enríquez-Cervantes, Cecilio; De la Peña-Almaguer, Erasmo; Jerjes-Sánchez, Carlos
ABSTRACT
Introduction: acute complications are common after a Mitral Valve (MV) replacement or annuloplasty. Ischemia induced by stenosis of the Circumflex Artery (CxA) caused by sutures of the MV annuloplasty is the most frequent acute complication.
Presentation of case: a 69-year-old woman with a successful MV annuloplasty performed five years previously presented with a four-month history of chest tightness on exertion. An exercise stress echocardiogram displayed ischemia and inferolateral wall hypokinesia. A coronary computed tomography angiography revealed extrinsic stenosis at the middle third of the CxA, close to the annuloplasty ring, consistent with coronary angiography findings. The cardiac magnetic resonance demonstrated inferolateral wall hypokinesia and basal inferolateral wall transmural necrosis. We performed a percutaneous coronary intervention with Intravascular Ultrasound (IVUS), showing the stenosis. We performed an angioplasty and stent placement with post-stent IVUS, which showed adequate angiographic apposition. The patient was discharged home two days later with optimal medical therapy.
Conclusion: chronic stenosis of the CxA after MV annuloplasty is extremely rare, with only four cases reported in the literature. A multimodal approach, including IVUS, can help identify the ischemia mechanism of a CxA chronic occlusion, supporting clinical decision-making to manage this complication.
