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Acute left main coronary artery occlusion following transcatheter aortic valve replacement without obvious risk factors of coronary obstruction.

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SUBMITTER: Cakal B

PROVIDER: S-EPMC7219302 | biostudies-literature | 2020 Apr

REPOSITORIES: biostudies-literature

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Acute left main coronary artery occlusion following transcatheter aortic valve replacement without obvious risk factors of coronary obstruction.

Çakal Beytullah B Çakal Sinem S Karaca Oguz O Boztosun Bilal B

Anatolian journal of cardiology 20200401 5

PMID: 32352418

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Project description:BackgroundAcute coronary obstruction following transcatheter aortic valve replacement (TAVR) is an uncommon but life-threatening event.Case summaryA 78-year-old man developed acute left main obstruction following transfemoral TAVR with a balloon-expandable valve. Cardiac arrest ensued, requiring emergent peripheral cardiopulmonary bypass. Percutaneous coronary intervention (PCI) to the left main coronary artery was performed with one drug-eluting stent. Intravascular ultrasound (IVUS) demonstrated focal underexpansion of the stent in its proximal segment which was not responsive to high-pressure non-compliant balloon dilatation, suggesting stent compression from either valve strut or calcific native leaflet. Therefore, to increase radial strength of the scaffolding at the site of compression, we deployed a second stent within the first stent, and further expanded that segment with high-pressure balloon inflations. Final IVUS demonstrated better expansion of the focally compressed segment. Following PCI, left ventricular function normalized completely. The patient was discharged from hospital on Day 3 post-procedure. At 12 weeks follow-up, his dyspnoea had improved significantly, and follow-up transthoracic echocardiography demonstrated normal left ventricular systolic function and normal aortic valve function.DiscussionEstablished risk factors for coronary ostial occlusion include a short distance between the aortic annulus and the coronary ostia (<10 mm) and a narrow aortic root (<28 mm at the sinuses of Valsalva). These two factors increase the likelihood that the native valve leaflets are displaced over and obstruct the coronary ostia when the aortic bioprosthesis is deployed. Perplexingly, our patient did not present with any of the recognized risk factors for acute coronary occlusion, suggesting other factors might be at play. We suggest that a leaflet length to coronary sinus height ratio greater than 1 might be an additional useful predictor of coronary occlusion during TAVR. In addition, we suggest that if residual focal stent compression from either valve strut or calcific leaflet exists after stent deployment and the latter is resistant to balloon dilatation, deploying a second concentric layer of stent might improve the radial strength of the scaffolding and improve overall stent expansion.

Project description:BackgroundCoronary obstruction during transcatheter aortic valve replacement (TAVR) is a rare, yet life-threatening, complication. The routine use of left main (LM) protection with or without stent placement in high-risk patients remains controversial. The aim of this study was to evaluate the outcomes of LM protection during TAVR and identify anatomic factors associated with need for stent placement.MethodsWe retrospectively reviewed all TAVR cases (native and valve-in-valve) performed in our institution between 2014 and 2019 and identified patients who underwent LM protection with a coronary wire, balloon, and/or stent during the procedure. We compared the pre-TAVR computed tomography aortic root characteristics, procedural data, short-, and long-term outcomes among the patients who eventually received an LM stent and those who did not.ResultsAmong 1925 TAVR patients, 41 (2.1%) underwent LM protection, and 10 of them (25%) had eventually a stent placed in the LM for threatened obstruction after valve deployment. In the native TAVR group (n = 35), 8 patients underwent LM stenting. A larger TAVR prosthesis, larger annular circumference (83.8 vs 76.1 mm; P = .038), lower ratio of sinotubular junction diameter to prosthesis size (1.02 vs 1.11; P = .032), and longer left coronary cusp (15.1 vs 13.9 mm; P = .18) were associated with higher incidence of LM stenting. In the valve-in-valve TAVR group (n = 6), 5 patients had a valve-to-coronary distance of less than 4 mm, and 2 of them received an LM stent. Both stent and nonstent groups had excellent outcomes with no major adverse cardiovascular events or coronary obstruction at 30 days. After a median follow-up of 351 days, 4 patients died (9.7%) (1 in the stent and 3 in the nonstent group), without any cases of late coronary obstruction or percutaneous coronary intervention in either group.ConclusionsLM protection with a coronary guidewire, balloon, or stent is a safe and effective method of coronary protection during TAVR in appropriately selected high-risk patients. Annular circumference, prosthesis size, left coronary cusp length, LM ostial height, and ratio of sinotubular junction to prosthesis size are important predictors of stent deployment.

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Acute left main coronary artery occlusion following transcatheter aortic valve replacement without obvious risk factors of coronary obstruction.

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Acute left main coronary artery occlusion following transcatheter aortic valve replacement without obvious risk factors of coronary obstruction.

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