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Acute left main stem coronary occlusion following transcatheter aortic valve replacement in a patient without recognized coronary obstruction risk factors: a case report

BACKGROUND: Acute coronary obstruction following transcatheter aortic valve replacement (TAVR) is an uncommon but life-threatening event. CASE SUMMARY: A 78-year-old man developed acute left main obstruction following transfemoral TAVR with a balloon-expandable valve. Cardiac arrest ensued, requirin...

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Autores principales: Spina, Roberto, Khalique, Omar, George, Isaac, Nazif, Tamim
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Oxford University Press 2018
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6426119/
https://www.ncbi.nlm.nih.gov/pubmed/31020188
http://dx.doi.org/10.1093/ehjcr/yty112
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author Spina, Roberto
Khalique, Omar
George, Isaac
Nazif, Tamim
author_facet Spina, Roberto
Khalique, Omar
George, Isaac
Nazif, Tamim
author_sort Spina, Roberto
collection PubMed
description BACKGROUND: Acute coronary obstruction following transcatheter aortic valve replacement (TAVR) is an uncommon but life-threatening event. CASE SUMMARY: A 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. DISCUSSION: Established 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.
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spelling pubmed-64261192019-04-24 Acute left main stem coronary occlusion following transcatheter aortic valve replacement in a patient without recognized coronary obstruction risk factors: a case report Spina, Roberto Khalique, Omar George, Isaac Nazif, Tamim Eur Heart J Case Rep Case Reports BACKGROUND: Acute coronary obstruction following transcatheter aortic valve replacement (TAVR) is an uncommon but life-threatening event. CASE SUMMARY: A 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. DISCUSSION: Established 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. Oxford University Press 2018-10-23 /pmc/articles/PMC6426119/ /pubmed/31020188 http://dx.doi.org/10.1093/ehjcr/yty112 Text en © The Author(s) 2018. Published by Oxford University Press on behalf of the European Society of Cardiology. http://creativecommons.org/licenses/by-nc/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com
spellingShingle Case Reports
Spina, Roberto
Khalique, Omar
George, Isaac
Nazif, Tamim
Acute left main stem coronary occlusion following transcatheter aortic valve replacement in a patient without recognized coronary obstruction risk factors: a case report
title Acute left main stem coronary occlusion following transcatheter aortic valve replacement in a patient without recognized coronary obstruction risk factors: a case report
title_full Acute left main stem coronary occlusion following transcatheter aortic valve replacement in a patient without recognized coronary obstruction risk factors: a case report
title_fullStr Acute left main stem coronary occlusion following transcatheter aortic valve replacement in a patient without recognized coronary obstruction risk factors: a case report
title_full_unstemmed Acute left main stem coronary occlusion following transcatheter aortic valve replacement in a patient without recognized coronary obstruction risk factors: a case report
title_short Acute left main stem coronary occlusion following transcatheter aortic valve replacement in a patient without recognized coronary obstruction risk factors: a case report
title_sort acute left main stem coronary occlusion following transcatheter aortic valve replacement in a patient without recognized coronary obstruction risk factors: a case report
topic Case Reports
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6426119/
https://www.ncbi.nlm.nih.gov/pubmed/31020188
http://dx.doi.org/10.1093/ehjcr/yty112
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