Acute Myocardial Infarction and Cardiac Arrest Due to Coronary Artery Perforation After Mitral Valve Surgery : Successful Treatment with a Covered Stent Harshal P. Sheth MD Rajiv S. Swamy MD Atman P. Shah MD FACC FSCAI University of Chicago Medical Center

History of Present Illness 82yo male with a bioprosthetic MVR (27mm Carpentier-Edwards Pericardial Valve) placed in 2002 secondary to infective endocarditis, presents with increasing dyspnea on exertion TTE: severe MS w/ a 26mmHg gradient and severe MR  elects for redo MVR Pre-op EKG NSR and coronary angiography revealed a 50% mid-RCA (co-dominant) stenosis

Initial Angiogram LAO View of LCA revealing LAD, co-dominant LCx free of disease and MVR LAO View of RCA revealing no focal epicardial stenoses

LAO Caudal Projection RAO Caudal Projection

Post-Operative Course MVR performed via lateral mini-thoracotomy approach Post-Op course uncomplicated; extubated day one; TTE shows normal LV function, no mitral stenosis Day 6, however, pt slumps over while working w/ physical therapy  telemetry shows ventricular tachycardia; cardiac arrest ensues ACLS resuscitation protocol initiated, pt orally intubated Shocked x 1 at 150J followed by epinephrine, continued CPR After fifteen minutes, return of spontaneous circulation achieved 12-lead ECG shows slow ventricular tachycardia and pt rushed to cardiac catheterization lab for further investigation

Left Coronary Angiograpy IABP AP Caudal view showing perforation (line) with filling of LA (circle) RAO Caudal View demonstrating free perforation of the LCx into the left atrium

3.0mmx12mm Coronary angioplasty balloon inflated to stop flow through the perforation 3.0mmx19mm JoStent Graftmaster stent positioned across the perforation

Final Angiogram JoStent deployed with no evidence of perforation and improved filling of the OM Equipment: -8Fr IABP via LCFA -7Fr EBU 3.5 Guide -0.014x300 Asahi Prowater -7000U Heparin (ACT>275) -3.0mmx12mm Apex Balloon -3.0mmx19mm Graftmaster JoStent Echocardiogram showed no pericardial effusion

LAO Cranial Projection RAO Caudal Projection

Balloon Across Perforation Prestent

Final Angiographic Result

Mitral Valve Surgery Approximately 30,000 mitral valve surgeries performed annually in the US, 10% being MV re-operations Statistically significant increase in bioprosthetic over mechanical each year Operative mortality for MV replacements = 3.8%1 Redo MV replacement conferred a 7.4% operative mortality risk; fifth most common cause was MI at 5% In absence of significant aortic insufficiency and concomitant CAD, MVR via right mini-thoracotomy is as safe as via traditional sternotomy with 30 day mortality rates of less than 3% for both MV replacement and repair with bleeding, infection, and atrial arrhythmias being most common (8.2%)2, 3 MVR re-operation in patients > 70 carries 10% mortality at one year4 In the available literature, the reported incidence of coronary artery perforation secondary to MVR is nonexistent 1Gammie JS et al. Ann Thorac Surg 2009; 87:1431-39. 2Umakanthan R et al. Ann Thorac Surg 2008; 85:1544-50. 3Seeburger J et al. Eur J Cardiothoracic Surg 2008; 34:760-65 4Awad W, et al. Eur J Cardiothoracic Surg 1997; 12:40-46.

JoStent Covered Coronary Stent Coronary perforation is reported to occur in 0.1%-3.0% of PCI, occurrence during CT surgery is very rare.1 An ultra-thin polytetrafluoroethylene (PTFE) graft placed between two stainless steel stents is the choice of therapy for coronary perforation (JoStent Graftmaster, Abbott Vascular) FDA indication for treatment of free perforations of either native coronary vessels or SVGs > 2.75mm in diameter and is approved as an HDE.2 Data limited, however, in retrospective analysis midterm to late data demonstrates no significant restenosis or mortality at 6 months; 0/41 patients receiving stent suffered q-wave MI or death.3 PTFE stents for routine use in SVG PCI has not shown any benefit.4 Difficulty in deployment and high restenosis rates of up to 30% have led to development types of covered stents, including a pericardial covered stent.5 1Gercken U, et al. CCI 2002;56:353-60 2Yilmaz H, et al. Int J Cardiol 2003;88:293-6 3Lansky J, et al. Am J Cardiol 2006;98:370-4 4Stankovic G, et al. Circ 2003;108:37-42 5Jokhi PP, et al. J Inv Cardiol 2009;21:E187-90.

Conclusion Discharged to rehab on POD 12, currently doing well. Pt was extubated the day following PCI and had no further VT 12-lead ECG following morning showed no q-waves Discharged to rehab on POD 12, currently doing well. Use of JoStent Graftmaster covered stent has never previously been reported in use for free perforation of a coronary artery as a complication of surgery After an extensive review of the literature, this is the first case of coronary perforation post MVR presenting as a VT arrest successfully treated with a covered stent.