Acute left main coronary occlusion after transcatheter aortic valve implantation: life-saving intervention using the snare technique—a case report

Abstract

Background Transcatheter aortic valve implantation (TAVI) has rapidly evolved and changed the field of structural cardiovascular intervention. Its advances lead to a marked reduction in the risk of complications and improved outcomes. However, TAVI is still associated with potential serious complications. Case summary A 73-year-old man with severe aortic stenosis underwent TAVI using a 34-mm self-expanding aortic bioprosthesis. After valve deployment, the patient rapidly progressed to cardiac arrest. Acute left main occlusion, due to high valve implantation, was promptly recognized and advanced life support immediately initiated. Concomitantly, the valve was successfully retrieved toward the ascending aorta using the snare technique, resulting in immediate restoration of flow and successful cardiopulmonary resuscitation. Subsequently, a 29-mm balloon-expandable aortic bioprosthesis was uneventfully implanted. After TAVI, the patient had a remarkable clinical evolution and was discharged home at hospitalization day 5 without relevant electrocardiographic nor echocardiographic disturbances. At 6-month follow-up, the patient remains asymptomatic and transthoracic echocardiography revealed a normofunctional aortic bioprosthesis with preserved left ventricular ejection fraction. Discussion Acute coronary occlusion is a rare and life-threating complication of TAVI that may be prevented with accurate procedure planning. Pre-procedural computed tomography angiography is essential for a comprehensive patient evaluation, allowing appropriate valve selection, a key factor for successful management. Self-expandable valve retrieval with snare technique can be an appropriate strategy for the management of this complication. This case highlights the importance of performing these procedures in highly experienced centers and with fully equipped catheterization laboratories to allow timely interventions when facing unexpected events.

Using Ping‐pong technique along with rapid inflate‐deflate ballooning to solve total left main occlusion during transcatheter aortic valve replacement procedure

“…Acute total occlusion during a TAVR procedure is less common but can become a life-threatening situation. 1,2 Patients at high risk of occlusion should undergo invasive primary prevention strategies to protect the coronary arteries, such as using a coronary guidewire and placing an undeployed stent in the periphery of the LAD. 4 In our case, we only used F I G U R E 7 Engage the left main stem (LMS) after rapid inflate and deflate ballooning.…”

“…Coronary artery obstruction (CAO) after transcatheter aortic valve replacement (TAVR) is a rare and life-threatening complication estimated to occur in less than 1% of cases, with a reported mortality rate of approximately 40%. 1 This condition is defined as a new partial or complete obstruction of either one or both ostia during a TAVR procedure, which typically manifests as abrupt hemodynamic instability, progressing rapidly into cardiogenic shock and ventricular arrhythmias. 2 The incidence of acute CAO occurs more often, about three to four times more frequently, in valve-in-valve procedures (2.3%-3.5%).…”

Coronary Artery Obstruction After Transcatheter Aortic Valve Implantation: Past, Present, and Future

“…However, if a self-expanding valve occludes the coronaries, due to migration or malposition, the valve can be snared and withdrawn into the ascending aorta or the aortic arch followed by immediate implantation of a second transcatheter valve. 38,39 The following interventional approaches have been described to mitigate the risk of CO:…”

TAVR Interventions and Coronary Access: How to Prevent Coronary Occlusion

“…The valve was quickly pulled toward the ascending aorta utilizing the snare technique, which immediately restored the flow and facilitated effective cardiopulmonary resuscitation. Following this, a 29 mm balloon-expandable Sapiens 3 valve was implanted successfully [39]. In general, the position of the second valve should be chosen to improve the procedure's results and reduce the risk of coronary occlusion and sinus compression.…”