Author + information
- Received January 27, 2014
- Accepted January 30, 2014
- Published online August 1, 2014.
- Gennaro Giustino, MD,
- Matteo Montorfano, MD,
- Alaide Chieffo, MD∗ (, )
- Vasileios Panoulas, MD,
- Pietro Spagnolo, MD,
- Azeem Latib, MD,
- Remo Daniel Covello, MD,
- Ottavio Alfieri, MD and
- Antonio Colombo, MD
- ↵∗Reprint requests and correspondence:
Dr. Alaide Chieffo, Interventional Cardiology Unit, San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy.
Coronary obstruction (CO) is a rare but potentially fatal complication in patients undergoing transcatheter aortic valve replacement (TAVR). CO is most commonly caused by the displacement of a calcified native aortic valve leaflet toward the coronary ostium (1).
An 89-year-old woman underwent transfemoral TAVR using a 26-mm CoreValve ReValving System (Medtronic, Minneapolis, Minnesota). Multidetector computed tomography (MDCT) scan showed an aortic annulus of 23 × 20 mm, a distance from the coronary ostium of 0.9 cm, and an aortic valve Agatston calcium score of 7,907 (Fig. 1A); calcifications appeared in close proximity to the left main coronary artery (LMCA) ostium.
Preparatory balloon aortic valvuloplasty was not performed because of the extensive calcifications. Immediately after implantation of the prosthetic valve, it appeared underexpanded, with a mean gradient of 43 mm Hg and moderate paraprosthetic aortic regurgitation (PPAR). Therefore, a 20-mm balloon post-dilation was performed, reducing the mean gradient to 8 mm Hg with no evidence of residual PPAR (Fig. 2D). Final nonselective angiographic control demonstrated good coronary perfusion (Fig. 2F).
Eight hours after the procedure, the patient complained of low-intensity atypical precordial pain. Electrocardiography showed a new-onset left bundle branch block, whereas the troponin T level was 1,733 ng/l. No hemodynamic instability was present. Echocardiography revealed an ejection fraction of 25% with anteroseptal–apical akinesias. Twelve hours later, the troponin T level rose to 2,268 ng/l. Subsequently, MDCT angiography was performed that showed subocclusion of the LMCA ostium (Fig. 1B), so the patient underwent emergency coronary angiography that confirmed the MDCT scan findings with severely reduced coronary blood flow (Thrombolysis In Myocardial Infarction [TIMI] flow grade 1). In order to restore LMCA perfusion, a percutaneous coronary intervention with implantation of a bare-metal stent 4.5 × 16 mm and noncompliant balloon post-dilation 5.0 × 12 mm at 24 atm was performed. Final selective LMCA angiography showed Thrombolysis In Myocardial Infarction flow grade 3 (Fig. 3). Despite the excellent angiographic result, the patient followed an adverse clinical course and died 5 days later.
This case highlights that CO after TAVR is a potentially lethal complication that can sometimes be very challenging to diagnose. In patients at risk in whom this complication is suspected, but clinical manifestations are not clear, MDCT coronary angiography, if readily available, is a good first-line noninvasive test, followed by urgent intervention if necessary.
Dr. Latib is a member of the advisory board of Medtronic; and is a consultant for Direct Flow Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received January 27, 2014.
- Accepted January 30, 2014.
- American College of Cardiology Foundation