A 56-year-old man with a history of advanced myocar-dipsia and biauricular orthotopic heart transplantation 7 years ago from a 40-year-old donor.
She presented an episode of humoral rejection four years after transplantation, which was successfully treated with methylprednisolone; at that time, coronary angiography was normal.
She had a history of hypertension and diabetes mellitus acquired after transplantation.
She was being treated with azathioprine and cyclosporine, as well as pravastatin, aspirin, enalapril and amyloidosis.
She was admitted for a 2-month history of moderate exertional angina, associated with dyspnea, which stopped with rest.
Physical examination revealed only a heart rate of 100 beats per minute and a fourth heart sound.
Resting electrocardiogram showed regular sinus rhythm, image of right bundle branch block with qS in the LV, anterior left hemiblock and nonspecific alterations of ventricular repolarization in the anterior wall.
Laboratory tests: blood glucose 175 mg/dL, creatinine 1.29 mg/dL, cholesterol LDL 62 mg/dL.
Endomyocardial biopsy was negative for cellular rejection.
Angiographic ventriculography revealed mild to moderate left ventricular dysfunction and anteroapical hypokinesia.
Coronary catheterization showed a critical ostial lesion of the LMCA, the anterior descending artery was occluded after the birth of the first diagonal branch and filled by heterocolateral from the right coronary artery.
No other significant coronary lesions were found.
After discussing the therapeutic alternatives with the patient, successful angioplasty of the LMCA lesion was performed, with direct implantation of sfewíTaxus® 3-5 x 22 mm with final flow 3.
A continuous 12-lead ST-segment recording detected significant and transient ST-segment depression in the V4 shunt during angioplasty.
No other incidents were recorded during and after the procedure.
On the seventh day, a scintigraphy with I131 MI was performed, showing uptake of the radiopharmaceutical anterior wall of the left ventricle.
The patient was discharged 4 days after angioplasty in good condition, the dose of statin increased (pravastatin 40 mg/day) and clopidogrel was added to his usual therapy.
Sixteen months after the procedure, the patient developed progressive dyspnea and a new coronary angiography was performed.
The absence of angiographic restenosis of the ICA and progression of atherosclerotic disease of the circumflex and right coronary arteries, which presented significant stenosis, were observed.
Myocardial revascularization surgery was performed: graft of the left internal mammary artery to the anterior descending artery and venous bridges saphenous to the anterior descending artery, collateral branch of the circumfleja artery and right coronary artery.
The patient required atrioventricular block after definitive implantation bicam.
Her evolution was satisfactory and she was discharged 14 days after the revascularization surgery.
