Abstract
Coronary obstruction is an uncommon and severe complication after a transcatheter aortic valve replacement (TAVR), that occurs during the procedure in the vast majority of patients. In the present case even in the absence of classic risk factors, an acute coronary syndrome occurred one day after TAVR. Selective angiography revealed a severe left main ostium obstruction by the bulky native leaflet calcification. This is the first case of delayed presentation of coronary obstruction with a transfemoral balloon-expandable valve using the Inovare bioprosthesis (Braile Biomedica, Brazil). In addition, after drug-eluting stent placement in the left main coronary, intravascular ultrasound revealed severe stent underexpansion, so that a second layer of a bare-metal stent and high-pressure balloon post-dilatation was necessary to improve the final result. The patient was discharged after 7 days, and at the 6-month follow-up remained asymptomatic.
<Learning objective: This case illustrates an unusual cause of an acute coronary syndrome 24 h after a transcatheter aortic valve replacement. This is the first report of this severe complication with delayed presentation following the balloon-expandable Inovare bioprosthesis. Even in the absence of classic risk factors this complication may occur, and percutaneous coronary intervention is feasible in the vast majority of cases, often requiring various percutaneous techniques and intravascular image to improve outcomes.>
Keywords: Delayed coronary obstruction, Transcatheter aortic valve replacement, Transfemoral approach, Inovare bioprosthesis
Introduction
Transcatheter aortic valve replacement (TAVR) has been an increasingly formal indication for patients with severe symptomatic aortic stenosis, and although complication rates have been hampered by the newer generation devices, some complications still occur. Of note, left main coronary (LMC) obstruction after TAVR is a rare but worrisome severe complication [1]. The clinical manifestations include rapid hemodynamic deterioration, ventricular arrhythmias, left ventricular dysfunction, and ischemic signs in the electrocardiogram, generally during valve implantation [2].
We describe the first case report of delayed LMC obstruction after transfemoral Inovare (Braile Biomedica, Brazil) implantation, presenting with a late non-ST elevation myocardial infarction (NSTEMI), managed successfully with overlapping stent implantation in the LMC, guided by intravascular ultrasound (IVUS).
Case report
An 84-year-old male with hypertension and aortic stenosis, presented with worsening dyspnea in the previous 4 months and one episode of syncope. In addition, due to progressive chest pain a cardiac catheterization was undertaken, revealing no coronary artery disease. Also, an echocardiogram showed critical aortic stenosis (mean gradient: 54 mmHg; aortic valve area: 0.6 cm2) and left ventricular ejection fraction (LVEF) of 35%. Due to age, frailty, and depressed LVEF, TAVR was scheduled. Multidetector computed tomography (MDCT) confirmed a suitable anatomy for TAVR (Fig. 1), so that a 26 mm balloon-expandable Inovare bioprothesis was implanted, using the transfemoral approach (Fig. 2; Video 1). After post-dilatation due to mild paravalvular leak, an excellent result was achieved with trace residual leak, mean gradient of 5 mmHg and recovery of LVEF without any segmental wall motion abnormality (LVEF: 55%). There was no hemodynamic instability, segmental ventricular deficit in the echocardiogram, or arrhythmias during the procedure. The patient was extubated the same day and remained stable without complaints.
Fig. 1.
Multidetector computed tomography (MDCT) showing high takeoff of left main coronary without calcification (white arrow) (A) and the right coronary arteries (B) of 1.5 and 1.2 cm, respectively. (C) Sinus of Valsalva diameters with bulky leaflet tip calcification in the left sinus (white arrow). (D) Aortic annulus area of 4.72 cm2.
Fig. 2.
Inovare bioprosthesis (Braile Biomedica, Brazil) of 26 mm implanted using the transfemoral approach. (A) Valve positioning. (B) Valve implantation under rapid pacing. (C) End control aortography showing a patent left main coronary despite the bulky calcification. No hemodynamic and electrocardiographic changes were noted during the procedure, and transesophageal echocardiogram revealed no segmental abnormality in contraction, with left ejection ventricular fraction (LVEF) recovery after valve implantation (LVEF from 35% to 55%).
On the following day after unremarkable recovery from TAVR, the patient started typical chest pain, that resolved after intravenous nitroglycerin. NSTEMI was diagnosed, due to significant peak in cardiac biomarkers (peak troponin I and creatine kinase-MB of >25,000 ng/L and 272 ng/mL, respectively). A cardiac catheterization was performed, revealing partial LMC obstruction in the ostium due to a bulky leaflet calcification (Fig. 3; Video 2). An IVUS confirmed a large semi-circumferential calcium mass protruding in the ostium (Fig. 3).
Fig. 3.
Post-transcatheter aortic valve replacement control angiography after the acute coronary syndrome. (A) Angiography revealing an evident bulky calcification between the prothesis and the aortic wall. Selective left main coronary artery injection revealing severe ostial lesion. (B) Pre-stenting intravascular ultrasound (IVUS) showing a severe luminal reduction with semi-circumferential calcification, and a minimal luminal area of 2.43 mm2 and diameter of 1.49 × 2.01 mm. (C) Percutaneous coronary intervention with a Promus premier (Boston Scientific, Natick, MA, USA) drug-eluting stent implantation (4.0 × 20 mm). (D) Despite multiple high pressure balloon post-dilatation control IVUS revealed significant stent underexpansion with minimal luminal area of 5.84 mm2 and diameter of 1.17 × 3.31 mm. (E) To further improve radial force an overlapping cobalt chromium Dynamic renal stent (Biotronik, Berlin, Germany) was implanted (120 μm of strut thickness). (F) IVUS revealed good stent expansion with minimal luminal area of 10.55 mm2 and diameter of 3.31 × 3.38 mm.
A percutaneous coronary intervention (PCI) was performed, using a 4.0 × 20 mm Promus Premier (Boston Scientific, Natick, MA, USA) drug-eluting stent (DES) with snorkeling technique [3]. Despite multiple post-dilatations with high pressure non-compliant balloon (4.0 × 15 mm; 4.5 × 15 mm; 5.0 × 15 mm), control IVUS indicated severe stent underexpansion in the ostium with minimal luminal area and diameters of 5.84 mm2 and 2.17 × 3.31 mm, respectively (Fig. 3; Video 3). A second 5.0 × 15 mm Dynamic Renal (Biotronik, Berlin, Germany) bare metal stent was implanted in the ostium to improve radial force. After non-compliant balloon post-dilatation (5.0 × 15 mm), control IVUS confirmed good stent expansion, with a minimal luminal area and diameter of 10.5 mm2 and 3.31 × 3.88 mm, respectively (Fig. 3; Video 4). The patient was discharged after 7 days on dual antiplatelet therapy, and at the 6-month follow-up was asymptomatic.
Discussion
This is the first case report of delayed coronary obstruction following transfemoral TAVR using Inovare bioprosthesis. This new device is a balloon-expandable valve, made of a cobalt-chromium alloy, an internal skirt composed of natural polyester graft, and bovine pericardium tissue with an anticalcifying treatment.
Despite favorable anatomical parameters in the MDCT, including high LMC takeoff with wide sinus of Valsalva, delayed coronary obstruction occurred [1,3]. The acute presentation of LMC obstruction has high mortality rates and generally occurs during the procedure, more frequently ensuing with hemodynamic instability or electrocardiographic changes due to LMC occlusion [4]. Still, subacute and late presentation may also occur in around 0.22% of patients undergoing TAVR, with similar presentation as in our case (NSTEMI) [5]. Risk factors for late occlusion are not well defined and appear to be multifactorial, and may include valve type (higher with self-expandable), low coronary take off, valve-in-valve procedure, and narrow sinus of Valsalva [1,3,5]. None of them was present in the current case, although a heavy burden of leaflet calcification was detected in the MDCT (Fig. 1), and this has also been highlighted as a possible risk factor [5]. Successful PCI is feasible in the vast majority of the patients, either with acute or delayed presentation [1,3,5], and intravascular imaging should be regarded as important adjunctive tool to improve percutaneous results and clinical outcomes as demonstrated in our case [2].
Even though great advances in the knowledge of TAVR complications, such as coronary obstruction, have been made, these complications still occur, so that future refinements are still needed in identifying its potential mechanisms. In addition, PCI could be recommended as a treatment strategy for most patients facing this complication, using intravascular imaging to optimize the result and avoid future reinterventions. Still, the heart team should be ready to place hemodynamic support and even change the strategy if needed.
Disclosures
Dr José Honório Palma is proctor and consultant for Braile Biomédica.
Conflict of Interest
Dr José Honório Palma is proctor and consultant for Braile Biomédica.
Funding Sources
The authors declare that there are no funding sources.
Footnotes
Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.jccase.2021.06.012.
Appendix. Supplementary materials
Video 1: Control aortography showing a patent left main coronary at the end of TAVR.
Video 2 Post-transcatheter aortic valve replacement control angiography after the acute coronary syndrome.
Video 3 Angiography result after percutaneous coronary intervention with a Promus premier (Boston Scientific, Natick, MA, USA) drug-eluting stent implantation (4.0 × 20 mm).
Video 4 Final angiography result after an overlapping cobalt chromium Dynamic renal stent (Biotronik, Berlin, Germany) implantation.
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Associated Data
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Supplementary Materials
Video 1: Control aortography showing a patent left main coronary at the end of TAVR.
Video 2 Post-transcatheter aortic valve replacement control angiography after the acute coronary syndrome.
Video 3 Angiography result after percutaneous coronary intervention with a Promus premier (Boston Scientific, Natick, MA, USA) drug-eluting stent implantation (4.0 × 20 mm).
Video 4 Final angiography result after an overlapping cobalt chromium Dynamic renal stent (Biotronik, Berlin, Germany) implantation.