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

Abstract

Background Coronary obstruction is one of the serious complications associated with transcatheter aortic valve implantation (TAVI). Delayed coronary obstruction (DCO) is a rare manifestation of coronary obstruction. Case summary A 91-year-old woman was diagnosed with severe aortic stenosis. She underwent TAVI with a self-expandable valve, without any complications. After 8 months, she was readmitted to our hospital for effort angina. Transthoracic echocardiogram and myocardial scintigraphy suggested left coronary artery ischaemia. Computed tomography revealed that the transcatheter heart valve (THV) frame was covered with a low-density mass that occluded the left coronary sinus (LCS). Transoesophageal echocardiogram showed a Doppler signal flowing from the non-coronary sinus to the LCS through the roundabout route between the aortic wall and the THV. Percutaneous coronary intervention was performed for the roundabout route. Although intravascular ultrasound after the implantation of one drug-eluting stent showed the underexpansion of the stent, another stent deployment improved the expansion. After the procedure, her symptom improved. Discussion Reportedly, the mechanism of DCO occurring months or years after TAVI is thought to be thrombus formation or THV endothelialization. In our case, the low-density mass was considered to be endothelium which developed along the THV frame. Low sinotubular junction height and higher THV position could be the underlying mechanisms of DCO. Percutaneous coronary intervention is a possible treatment option for DCO caused by THV endothelialization.

Rare Cause of Late Left Aortic Sinus Obstruction Following Transcatheter Aortic Valve Replacement

“…In that case, the coronary stent was placed outside the valve stent. 4 We decided to treat this patient with PCI presuming that the mechanism was endothelization or thrombus formation, both of which we could not diagnose with absolute certainty. Although the higher tissue characterization obtained by optical coherence tomography would have been helpful to achieve a more definitive diagnosis, we were concerned about the inability to clear blood to gather a good optical coherence tomography image because the lesion was not in a coronary artery.…”

Real world coronary artery ostia full accessibility after last generation transcatheter aortic valve implantation

“…On the contrary, self-expandable valves implantation presented a negative correlation with age and time after TAVI. The high frame of the self-expandable valve and their partial endothelization over the time 14 , 15 might explain an increased difficulty in engaging the coronary ostia later after such valve implantation over the time. Moreover, with no difference between balloon-expandable and self-expandable valves, the neo-commissures may interfere with coronary orifices and affect coronary access.…”