Late Coronary Ostial Stenosis After Complicated Bentall–De Bono Procedure

Abstract

Background

Coronary ostial stenosis (COS) is a rare but potentially fatal complication following the Bentall–De Bono procedure.

Case Summary

A 59-year-old man with prior Bentall–De Bono surgery along with venous graft reconstruction presented 8 years later with heart failure. Coronary computed tomography angiography demonstrated venous graft ostial stenosis, and cardiac magnetic resonance confirmed a transmural infarction with impaired ventricular function. Given the complex coronary anatomy and limitations to percutaneous treatment, the Heart Team opted for urgent surgical revascularization.

Discussion

COS after aortic root replacement results from multifactorial mechanisms, including surgical trauma, excessive tension, kinking, or fibrosis related to adhesives, whereas venous graft stenosis adds further complexity. Diagnosis is often challenging because coronary angiography may underestimate the disease while coronary computed tomography angiography and cardiac magnetic resonance offer superior anatomical and functional assessments, enabling accurate detection and guiding timely revascularization.

Take-Home Messages

COS represents an uncommon yet life-threatening complication of aortic root replacement. Advanced multimodal imaging is pivotal to precise diagnosis and therapeutic guidance. Prompt, tailored revascularization strategies are essential to improving clinical outcomes.

Visual Summary

The Bentall–De Bono procedure, originally described in 1968, entails composite graft replacement of the aortic root with concomitant prosthetic aortic valve implantation and coronary artery reimplantation and has since become the standard surgical approach for a broad spectrum of aortic root pathologies.^1,2 Outcomes reported following Bentall procedures with mechanical prostheses include an early postoperative mortality of 5.6% and a reoperation rate of 1.01% per year.³

Take-Home Messages

• •Coronary ostial stenosis represents an uncommon yet life-threatening complication of aortic root replacement.
• •Advanced multimodality imaging is pivotal for precise diagnosis and therapeutic guidance.
• •Prompt, tailored revascularization strategies are essential to improve clinical outcomes.

Coronary ostial stenosis (COS) is a rare complication following aortic root replacement with an incidence of 1% to 3%.⁴ While uncommon, these events may be catastrophic, and their true frequency is probably underestimated, since some deaths following surgery may be caused by unrecognized COS.⁵

In patients with associated coronary artery disease or coronary involvement secondary to dissection, coronary artery bypass grafting (CABG) may be performed during the Bentall procedure. As limited cases have undergone Bentall coupled with CABG using venous grafts, the management of post-Bentall patients with vein graft stenosis is complex and challenging.¹

This case report describes a patient with a history of a complicated Bentall–De Bono procedure who developed an anterior myocardial infarction caused by ostial coronary stenosis, identified through a multimodal imaging assessment.

Case Presentation

A 59-year-old man was admitted for further evaluation following the presentation of congestive heart failure with good response to diuretic therapy, describing an episode of brief, intense chest pain 2 days earlier. Past medical history included a bicuspid aortic valve, severe aortic regurgitation, and ascending aortic dissection (Figure 1) repaired with a Woven Dacron graft (Vascutek Ltd) and a 25-mm Sorin aortic mechanical valve (Sorin Group) implanted during a Bentall–De Bono procedure performed 8 years earlier but complicated by left anterior descending artery (LAD) perforation that required venous graft reconstruction.

Figure 1.

Multimodal Imaging Assessment Before the Bentall–De Bono Procedure

Severe aortic regurgitation with a bicuspid aortic valve and ascending aortic dissection without perfusion defects: (A) Coronal cine CMR view of the left ventricular outflow tract. (B) Three-chamber cine CMR view of the left ventricular outflow tract. (C) Short-axis cine CMR view at the level of the aortic valve. (D) Short-axis CT view. (E) Two-chamber CT view. CT = computed tomography; CMR = cardiac magnetic resonance.

On admission, vital signs showed tachycardia with a heart rate of 102 beats/min, respiratory rate of 22 breaths/min, blood pressure of 104/77 mm Hg, and peripheral oxygen saturation of 97% in room air. Physical examination was relevant due to pulmonary crackles. Electrocardiography demonstrated a new-onset left bundle branch block, absent in the immediate postoperative period after the Bentall–De Bono procedure (Figure 2). Laboratory tests revealed elevated N-terminal pro–B-type natriuretic peptide with a decreasing trend from 5,598 pg/mL to 2,907 pg/mL (reference <386 pg/mL) and elevated troponin with a decrease from 6,029 pg/mL to 5,490 pg/mL (reference <14 pg/mL).

Figure 2.

Electrocardiogram

(A) At hospital discharge after Bentall–De Bono procedure: left ventricular hypertrophy, left atrial enlargement, and left anterior fascicular block. (B) Current admission: sinus tachycardia with new-onset left bundle branch block.

Given the suspicion of a coronary complication, coronary computed tomography angiography (CCTA) revealed a venous graft to the LAD with a retroaortic course and acute takeoff angle, demonstrating ostial stenosis with perfusion defects predominantly in the LAD territory, without lesions in either the circumflex or the native LAD (Figure 3).

Figure 3.

Cardiac Computed Tomography

Venous graft to the left anterior descending artery (LAD) with a retroaortic course and acute takeoff angle, showing ostial stenosis (red dotted line) with corresponding perfusion defects (white arrows): (A) Axial CT view at the level of the venous graft to the LAD, (B) oblique maximum intensity projection view of the LAD, (C) straight multiplanar reconstruction of LAD, (D) 2-chamber CT view, (E) basal short-axis CT view, (F) VRT 3D reconstruction, anterior view, (G) VRT 3D reconstruction, posterior view. LAD = left anterior descending coronary; VRT = volume rendering technique.

Cardiac magnetic resonance revealed a transmural infarction with focal intramyocardial hemorrhage and microvascular obstruction in the LAD territory, left ventricular ejection fraction of 31%, and a normally functioning aortic mechanical prosthetic valve (Figure 4, Videos 1 and 2). Considering the complex coronary anatomy, significant left main disease, absence of infarction in the circumflex with preserved contractile function, and the challenges of percutaneous management, the Heart Team opted for surgical revascularization and referred the patient for cardiac surgery. CABG was performed using the left internal mammary artery to the LAD, a saphenous vein graft from the ascending aorta to the first diagonal branch, and a left radial artery Y-graft originating from the venous conduit to the first obtuse marginal branch, with the procedure completed uneventfully.

Figure 4.

Cardiac Magnetic Resonance

(A) Cine image showing hypokinesia of the septal, anterior, and anterolateral walls. (B) T2-weighted image showing high-signal intensity in the anteroseptal, anterior, and anterolateral walls. (C) Native T1 mapping demonstrating reduced values in the anteroseptal, anterior, and anterolateral walls (902 ms). (D) Postcontrast T1 mapping showing elevated extracellular volume of 44% in the anteroseptal, anterior, and anterolateral walls. (E) T2 mapping within normal limits (36 ms). (F) T2∗ mapping demonstrating focal areas of reduced values in the anterior wall (12 ms). (G) First-pass perfusion revealing perfusion defects in the anteroseptal, anterior, and lateral walls with involvement of the anterolateral papillary muscle. (H and I) Late gadolinium enhancement images showing a transmural pattern in the anteroseptal, anterior, and lateral walls, with associated microvascular obstruction in the anterior wall and intramyocardial hemorrhage in the lateral wall.

The patient received guideline-directed medical therapy for heart failure, together with antiplatelet agents, vitamin K antagonist anticoagulant, and high-intensity statin therapy. He was discharged asymptomatic and, at 1-month follow-up, remained clinically stable without arrhythmias. Close surveillance was arranged at the ischemic heart disease department.

Discussion

COS is a recognized but challenging complication after aortic root replacement involving reimplantation of the coronaries, with a multifactorial pathogenesis. Proposed mechanisms include intimal fibrosis, direct surgical trauma, excessive tension at the anastomotic site, and coronary kinking.^4,6 Additional contributors are mechanical compression from hematoma or thrombus, coronary vasospasm, and undiagnosed pre-existing coronary artery disease.⁶

Gelatin–resorcinol–formalin glue has been particularly implicated, as it can provoke localized inflammation and fibrosis leading to progressive ostial narrowing and resistance to percutaneous revascularization.4, 5, 6 Other potential causes include stretching or twisting of the vessels during mobilization, imperfect suturing of the coronary buttons, and in rare cases, retrograde propagation of type A dissection into the coronary ostia.⁵ In addition, vein graft stenosis, when present, follows a complex pathophysiology involving intimal hyperplasia, atheromatous degeneration, and superimposed thrombus formation, resembling processes observed in native coronary arteries.¹

Anastomotic complications can have catastrophic consequences, and the risk is further heightened in patients with systemic inflammatory disorders such as Takayasu arteritis, in whom chronic vascular inflammation predisposes stenosis, occlusion, or anastomotic dehiscence.⁷ COS may therefore manifest with a wide clinical spectrum, ranging from atypical chest pain to acute coronary syndromes, cardiogenic shock, or sudden death, most frequently within the first 6 months after surgery, although late presentations have also been reported.5, 6, 7

The diagnosis of COS is often challenging because conventional angiography may underestimate the disease when only limited projections are obtained or when sub-selective cannulation prevents adequate contrast reflux into the aorta. In this context, CCTA provides higher diagnostic yield by enabling accurate detection of ostial narrowing, guiding invasive views, and allowing reliable postprocedural evaluation.⁴

CCTA provides multiplanar reconstructions, quantification of plaque density, and virtual histology for refined grading of stenosis.⁵ These advantages translate into excellent diagnostic performance for postsurgical aortic and coronary complications, with sensitivity of 90% to 95% and specificity of 90% to 98%.⁸

Cardiac magnetic resonance complements CCTA by offering radiation-free imaging, superior soft-tissue contrast, and advanced functional assessment with 4D flow techniques, particularly valuable in younger patients or those requiring long-term follow-up. In addition, novel imaging strategies, such as dual-energy computed tomography, dynamic computed tomography perfusion, and artificial intelligence-based radiomics, are being incorporated to enhance detection, tissue characterization, and risk stratification.⁸

Ischemia detected immediately after aortic root replacement often mandates urgent surgical reintervention. The most frequent approach involves coronary button resiting or CABG, particularly when mechanical causes such as tension, kinking, or glue-related compression of the coronary buttons are identified. Surgical revision may require refashioning of the coronary button to relieve obstruction and restore flow.⁶

Therapeutic strategies must be individualized, considering the patient's anatomy, the timing of ischemia, and the clinical presentation. Current guidelines endorse CABG as the standard treatment for unprotected left main coronary disease;⁵ however, reoperation in the early postoperative period after root replacement carries a high risk of perioperative infarction and mortality.⁶ Furthermore, when CABG is performed in this setting, long-term graft patency may be jeopardized by competitive flow from the native coronary ostium.⁶

Surgical coronary revascularization provides a survival benefit over medical therapy and plays a central role in the setting of ST-segment elevation myocardial infarction, where emergency CABG is an effective reperfusion strategy when percutaneous treatment is not feasible and a large myocardial territory is at risk, particularly in the presence of ongoing ischemia, severe heart failure, or life-threatening arrhythmia. Outcomes are influenced by conduit selection, with the radial artery preferred over saphenous vein grafts for secondary targets beyond the LAD, and CABG remains reasonable in stable ischemic heart disease with ventricular dysfunction as well as in patients with prior surgery when an internal mammary artery can be used as a conduit to the LAD, highlighting its importance in complex revascularization.⁹

In hemodynamically unstable patients, percutaneous coronary intervention constitutes the most effective emergency salvage therapy. Prompt revascularization with coronary stenting often results in rapid hemodynamic stabilization and resolution of ischemic changes, providing a life-saving alternative when surgical risk is prohibitive.⁶

Follow-up imaging is essential, as CCTA provides detailed visualization of the tubular graft, prosthetic valve, and coronary reimplantation sites, thereby enabling the detection of ostial obstruction, kinking, or malpositioning, while the differentiation between normal postoperative appearances and true pathology remains crucial to avoid misinterpretation and unnecessary intervention.⁸

Conclusions

COS remains a rare but potentially fatal complication after aortic root replacement, often presenting with diagnostic and therapeutic challenges. Multimodal imaging plays a pivotal role in identifying these lesions and guiding management, while timely individualized revascularization strategies, whether surgical or percutaneous, are crucial to improve outcomes and prevent catastrophic events.

Visual Summary.

Late Coronary Ostial Stenosis After a Complicated Bentall–De Bono Procedure: Multimodal Imaging Assessment

Funding Support and Author Disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Appendix

Video 1

Cardiac Magnetic Resonance

Two-chamber cine view with hypokinesia of the anterior wall.

Video 2

Cardiac Magnetic Resonance

Short-axis cine view at the basal ventricular level with hypokinesia of the septal, anterior, and anterolateral walls.