Acute Myocardial Infarction Shortly After Valve-in Valve Transcatheter Aortic Valve Implantation (TAVI) Successfully Managed With An Apparently Challenging Percutaneous Coronary Intervention

Abstract

In recent years, transcatheter aortic valve implantation (TAVI) has been considered a novel option for the management of surgically high-risk patients requiring aortic valve replacement. Presently described is a case of acute coronary syndrome (ACS) managed with a challenging primary percutaneous coronary intervention (PCI) shortly after a valve-in-valve TAVI intervention. This case highlights 2 important issues: PCI may be an option for the management of coronary heart disease in patients after TAVI even in the setting of demanding features associated with coronary osteal engagement, and secondly, TAVI may serve as a potential risk factor for future coronary ischemic syndromes, largely due to its potential adverse effects on coronary flow dynamics, etc. However, the latter notion is quite speculative, and should be tested in further studies.

Late coronary ischemıc syndromes assocıated wıth transcatheter aortıc valve ımplantatıon: A revıew of mechanıstıc and clınıcal aspects

“…Interestingly, clinicians are generally inclined to consider these life-threatening readmissions as part of a natural and anticipated course of these high-risk patients, and do not contemplate over any spesific triggers and mechanisms underlying these coronary ischemic syndromes emerging after TAVI. In our clinical practice, we also encounter such cases readmitted with acute coronary ischemic syndromes emerging without a spesific trigger after TAVI 10 . Similarly, readmissions with acute myocardial infarction (AMI) following TAVI were also reported in previous large-scale studies 8 , 9 .…”

“…Importantly, this was reportedly the first study directly comparing surgical and transcatheter aortic valve interventions in patients with a relatively low surgical risk 4 . Taken together, the incidence of AMI might be relatively rare in the short and mid terms after TAVI, and appears to be comparable between self and baloon expandable valves 8, 9, 10, 11. However, there exists an upward temporal trend in the incidence of AMI readmissions on longer clinical follow-up 12, 13…”

“…More importantly, even though coronary ischemic syndromes emerging after TAVI might, to some extent, be regarded as a coincidental phenomenon arising spontaneously or due to a variety of stressors, 8−13 TAVI, per se, may have the potential to directly account for or accelerate the emergence of coronary ischemia as well. Taken together, it seems reasonable that TAVI, at the cost of treating the diseased aortic valve, may potentially elicit a significant proclivity for late coronary ischemic events (even in the setting of an uneventful periprocedural course) in the short and long terms through a variety of subtle mechanisms 10 particularly in the presence of certain risk factors (as described below). On the other hand, studies with longer follow-up periods directly comparing patients with and without TAVI with regard to the evolution of coronary ischemic syndromes are strongly needed to draw firm conclusions on this issue.…”

“…On the other hand, potential impact of TAVI at the macrovascular level may be considered as a relatively more common and striking phenomenon in the clinical setting. Accordingly, impaired epicardial coronary flow dynamics (including reduced flow with intra-coronary stasis) with or without in-situ coronary thrombus formation may emerge as a dominant mechanism of late coronary ischemic events emerging after TAVI 10 . In the literature, in-situ coronary thrombus formation was previously suggested as a potential cause of acute and late-onset coronary ischemic symptoms after TAVI 10 , 22 .…”

Mechanically expanding transcatheter aortic valves: pros and cons of a unique device technology

“…In the recent years, transcatheter aortic valve implantation (TAVI) has gained a significant reputation as an alternative option for the management of aortic valve disease particularly in the setting of high-risk conditions for surgical aortic valve replacement (SAVR) (1)(2)(3). In the wellknown PARTNER-1 trial, TAVI was found to be associated with a significant mortality benefit in comparison to standard treatment among patients with aortic valve stenosis (AVS) (1).…”