A case of acute coronary syndrome caused by delayed coronary ischemia after transcatheter aortic valve implantation

Abstract

An 84-year-old female patient suffered from dyspnea due to severe aortic stenosis. Several comorbidities and her advanced age made her acceptable for transcatheter aortic valve implantation (TAVI). The TAVI procedure was performed via a femoral access and a 26-mm CoreValve prosthesis (Medtronic, Minneapolis, MN, USA) was implanted. The prosthesis was deployed at a high position because of short distance between the annulus base and coronary arteries. Aortic angiography indicated normal contrast flow into both coronary arteries. Six months later she was readmitted to our hospital because of acute coronary syndrome. Although selective intubation of coronary arteries could not be achieved because of high valve position, both coronary arteries seemed to be well contrasted. As a consequence, the second coronary angiography was undertaken because of recurring chest pains. The aortic root angiogram showed a decreased contrast flow into both coronary arteries. During the examination she deteriorated rapidly, developed cardiopulmonary arrest, and a percutaneous cardiopulmonary support and an intra-aortic balloon pump needed to be inserted. She was then transferred to the operating room for aortic valve replacement. This is the first case of delayed coronary ischemia after TAVI, necessitating the removal of an implanted CoreValve and its replacement with a new prosthetic valve. <Learning objective: The higher position of the CoreValve implanted in the transcatheter aortic valve implantation (TAVI) procedure can rarely induce coronary obstruction, especially in patients with low lying coronary ostia and a small sinus of Valsalva. Percutaneous coronary intervention and coronary artery bypass graft are sometimes difficult in these patients, and replacement of the prosthetic valve may be an alternative. Patients with higher CoreValve position require close follow up to recognize any coronary perfusion defects at an early stage.>

Surgical explantation of transcatheter aortic bioprostheses: Results and clinical implications

“…As for previous TAVR valve explant and recommended surgical technique in the literature, we have identified 11 case reports that involved description of valve explant technique from 2008 to 2019. 4,10,[15][16][17][18][19][20][21][22][23] The time interval between TAVR implant and explant was from immediate to 7 years (median 187 days; IQR, 21-913 days). Surgical explantation of older TAVR valve cases are increasingly reported recently, being exclusively after 2015.…”

Percutaneous coronary intervention for delayed coronary obstruction due to endothelialization of self-expandable transcatheter heart valve: a case report

“…Some reports of late surgical complications of self-expandable THV revealed that the stent frame was infiltrated with endothelium and embedded in the aortic wall, especially at the STJ. 4 , 5 THV thrombosis can be detected using CT by a hypo-attenuated leaflet thickening. Anticoagulation therapy can improve thrombosis.…”

“…In a previous case report of DCO due to THV endothelialization, the patient was treated surgically. 4 In our case, we first determined whether PCI was a possible treatment option for DCO due to THV endothelialization by implanting stents in the roundabout route and making a new orifice in the NCS.…”

Delayed Valsalva obstruction after transcatheter self-expandable aortic valve implantation: a case report

“…Ninomiya et al . 10 reported a case of acute coronary syndrome caused by delayed coronary ischaemia after transcatheter self-expandable aortic valve implantation and revealed that a higher position of the self-expandable valve might induce coronary obstruction, especially in patients with small sinuses of Valsalva. In the present case, the commissural post accidentally overlaid the left coronary artery ostium, and the left coronary cusp was gradually blocked by the supra-annular valve.…”