Thrombotic complications associated with transcatheter aortic valve implantation: the role of Kounis hypersensitivity-associated thrombotic syndrome

Incidence, outcomes, and predictors of in‐hospital acute coronary syndrome following endovascular transcatheter aortic valve replacement in the United States

“…Several potential mechanisms have postulated in TAVR‐ associated ACS. These include atherothrombotic progression of CAD, periprocedural stresses in patients inadequately revascularized before TAVR, direct obstruction of coronary flow at the coronary ostia as a result of mechanical obstruction from the TAVR bioprosthesis due to initial placement or migration, subclinical aortic bioprosthetic leaflet thrombosis causing coronary embolism, and Kounis syndrome, a hypersensitivity reaction against metal anions present in the aortic bioprosthesis 20–25 . The exact prevalence and incidence of ACS among older adults (≥ 75 years of age) is not well known, as these patients have typically been underrepresented in ACS clinical trials 26 .…”

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

“…Within this context, measurement of fractional flow reserve (FFR) and coronary flow velocity might confirm TAVI-induced changes in epicardial coronary physiology in certain settings. These alterations may be huge enough to exclusively account for the evolution of coronary ischemia regardless of pre-existing coronary stenosis or superimposing coronary thrombus, and may be even more pronounced in the setting of self-expandable and valve-in valve TAVI (even though self-expandable valves as compared with balloon-expandable ones are generally less likely to elicit acute coronary osteal occlusion, 23 their chronic effects on coronary system might be more striking largely due to their relatively bulky nature and superimposing stent struts on the coronary ostia). Accordingly, impaired coronary flow and perfusion may be the sole finding without associated intracoronary thrombus in a portion of post-TAVI patients with coronary ischemic syndromes who mostly present with a stable coronary artery disease (CAD) or non-ST elevation-ACS (NSTE-ACS).…”

“…Interestingly, it was previously suggested that hypersensitivity reactions (including Kounis syndrome) against the implanted device material might also serve as a potential trigger of coronary thrombus formation in certain settings 23 , 24 . Kounis syndrome is characterized by acute spasm and/or thrombotic occlusion of coronary arteries in response to certain allergic triggers (drugs, food,etc.)…”

“…as well as bioactive amines including histamine, etc. with a variety of detrimental effects on coronary vasomotion and atherosclerotic plaque stability 23 , 24 . More importantly, implanted cardiac devices including coronary stents, TAVI bioprostheses, etc.…”

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

“…However, SEVs were found to be associated with a lower device success as measured with higher rates of paravalvular leak (PVL) and the need for more than one valve in the same session along with a higher propensity for new-onset conduction disturbances requiring permanent pacemaker implantation (PPI) (9,13). On the other hand, BEVs are more likely to elicit potentially fatal complications including annular rupture and coronary osteal occlusion particularly in the setting of certain risk factors (8,11,14). Moreover, firstgeneration SEVs and BEVs are not amenable to valve repositioning or retrieval potentially leading to device malapposition along with device failure, PVL, coronary osteal occlusion and valve-in valve procedures in certain settings (8,12).…”