Severe Stenosis at the Ostium of the Left Sinus of Valsalva Long After Surgical Aortic Valve Replacement

A 70-year-old woman who underwent surgical aortic mechanical valve replacement 20 years ago presented with unstable angina. Angiography showed no significant coronary stenosis but an abnormal structure occupying the left sinus of Valsalva (Figure A). Intravascular ultrasound (IVUS) revealed fibrous tissue narrowing the ostium of the left sinus of Valsalva, suggesting pannus ingrowth from the prosthetic valve (Figure B, Supplementary Movie 1). A pressure wire study showed severe ischemia at rest (distal coronary artery pressure/aortic pressure (Pd/Pa)=0.50; diastolic pressure ratio (dPR)=0.39) (Figure C). The patient did not have clinical features of aortitis or other inflammatory diseases that could cause pannus overgrowth.

Figure.

(A) Aortography shows an abnormal structure in the Valsalva (*). (B) Intravascular ultrasound (IVUS) shows web-like (arrows) and slit-like (*) fibrous tissue narrowing the lumen. (C) Pressure wire showing severe ischemia at rest. (D) Balloon angioplasty. (E) Subsequent IVUS showing the compressed fibrous tissue (*). (F) Physiological indices increased without stenting. dPR, diastolic pressure ratio; FFR, fractional flow reserve; LMCA, left main coronary artery; Pd/Pa, distal coronary artery pressure/aortic pressure.

Because reoperation was deemed high-risk, the heart team selected percutaneous coronary intervention as the treatment strategy. Balloon angioplasty was performed with a 6.0-mm non-compliant balloon (Figure D). Subsequent IVUS showed successful lumen enlargement (Figure E, Supplementary Movie 2). Physiological indices increased dramatically (resting Pd/Pa=0.99, dPR=0.98, fractional flow reserve =0.92) (Figure F). It was decided not to implant a stent. The procedure was completed with a 4.0-mm drug-coated balloon dilatation.

Although subaortic pannus formation sometimes leads to prosthetic valve failure,¹ coronary obstruction due to pannus ingrowth is a rare but serious complication after surgical aortic valve replacement.² Although coronary angiography is essential to diagnose obstructive coronary disease, the method sometimes has limitations in the evaluation of disease morphology, severity, and response to intervention, especially in ostial lesions. This case suggests the utility of intravascular imaging/physiological indices in elucidating lesion severity and the therapeutic effects on obstruction at the Valsalva by pannus ingrowth.

Disclosures

T.N. serves as an Associate Editor of Circulation Journal. Other authors have nothing to disclose.

Supplementary Files

Supplementary Movie 1. IVUS before balloon dilatation.

Supplementary Movie 2. IVUS after balloon dilatation.

Please find supplementary file(s);

http://dx.doi.org/10.1253/circj.CJ-21-0522

References

• 1.   Park PW, Park B, Jeong DS, Sung K, Kim WS, Lee YT, et al. Clinical outcomes of repeat aortic valve replacement for subaortic pannus in mechanical aortic valve. Circ J 2018; 82: 2535–2541.
• 2.   Pillai JB, Pillay TM, Ahmad J. Coronary ostial stenosis after aortic valve replacement, revisited. Ann Thorac Surg 2004; 78: 2169–2171.