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A challenging case of transcatheter aortic valve implantation under left main coronary artery protection/ Sol ana koroner arter korumasi altinda yapilan zorlu bir transkateter aort kapak implantasyon vakasi.

For patients presenting with severe aortic stenosis having high risk for surgery transcatheter aortic valve implantation (TAVI) is an alternative therapy. TAVI is associated with major complications including, valve embolization, stroke, perforation, coronary obstruction, atrioventricular block (1-5). Herein we presented a case of aortic stenosis that had a small distance of coronary to annulus, treated successfully with transfemoral TAVI under left main coronary artery (LMCA) protection.

An 85-year-old man with severe symptomatic aortic stenosis presented with dyspnea and angina despite medical treatment. The patient had high risk for surgery. Computed tomography demonstrated moderate tortuosity of iliac arteries. The annulus diameter was measured 23mm at transesophageal echocardiography. The annulus to LMCA ostial distance was measured 10 mm on aortography (Fig. 1A). Thus transfemoral TAVI with 26 mm Edwards Sapien XT valve was planned after informed consent was taken. The transient pacemaker was implanted through left femoral vein to apex of right ventricle. A 6F sheath was introduced to the left and right common femoral arteries under fluoroscopy. A pigtail catheter was introduced to the ascending aorta through left femoral artery. The transient pacemaker was implanted to the right ventricular apex. A Judkins right-4 catheter was introduced to the ascending aorta over a regular 0.38 guide wire from right common femoral artery. The guide wire was exchanged with a 0.035 Amplatz extra stiff guide wire than 6F sheath was exchanged with E-sheath. The calcified left coronary cusp partially obstructed the left main coronary ostium during the aortic balloon valvuloplasty without hemodynamic compromise (Fig. 1B, Video 1. See corresponding video/ movie images at www.anakarder.com). Because of the risk of LMCA obstruction a 7F catheter was introduced to the left common femoral artery than LMCA was engaged with a 7F Judkins left 4 guiding catheter. The floppy coronary wire was advanced through the LMCA to the left anterior descending coronary artery (LAD) and a 3.0x15 mm coronary balloon was crossed to the LAD over the guide wire (Fig. 2A, Video 2. See corresponding video/movie images at www.anakarder.com). Then guiding catheter was disengaged 1 cm above from LMCA ostium. The valve was successfully implanted (Fig. 2B, Video 3. See corresponding video/movie images at www.anakarder.com). Control angiography showed patent LMCA thus the guide wire and balloon was removed (Fig. 2C, Video 4. See corresponding video/movie images at www.anakarder.com). Control aortography revealed successfully implanted aortic bioprosthetic valve with patent coronary arteries (Fig. 2D).

Left main coronary artery obstruction is a life treating complication of TAVI, associated with inappropriately high positioning of valve, embolization of atheroma, calcium, thrombus, narrow sinus of Valsalva, bulky leaflet calcifications, and low-lying coronary ostia (1-5). It is crucial to assess these factors before the procedure. Also aortography during the balloon valvuloplasty is important to determine this complication. During balloon aortoplasty bulky leaflets may transiently occlude the LMCA ostium. This patient had enough coronary ostia to annulus diameter. During the balloon angioplasty, the LMCA ostium was transiently narrowed without hemodynamic compromise. Hence, the implantation of the valve was conducted under the protection of LMCA.

Control angiogram during aortic balloon angioplasty may be beneficial to take appropriate measures to handle with probable complications including LMCA obstruction during the TAVI.

Video 1. The calcified left coronary cusp partially obstructed the left main coronary ostium during the aortic balloon valvuloplasty

Video 2. A the floppy coronary wire was advanced through the LMCA to the left anterior descending coronary artery and a 3.0x15 mm coronary balloon was crossed to the LAD over the guidewire

LAD--left anterior descending artery, LMCA--left main coronary artery

Video 3. A 26-mm Edwards Sapien XT (Edwards Lifesciences, Irvine, California) aortic bioprosthesis) was successfully implanted

Video 4. Control angiography showing patent LMCA

LMCA--left main coronary artery

References

(1.) Dagdelen S, Karabulut H, Alhan C. Acute left main coronary artery occlusion following TAVI and emergency solution. Anadolu Kardiyol Derg 2011; 11: 747-8.

(2.) Holmes DR Jr, Mack MJ, Kaul S, Agnihotri A, Alexander KP, Bailey SR, et al. 2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement. J Am Coll Cardiol 2012; 59: 1200-54.

(3.) Masson JB, Kovac J, Schuler G, Ye J, Cheung A, Kapadia S, et al. Transcatheter aortic valve implantation: review of the nature, management, and avoidance of procedural complications. JACC Cardiovasc Interv 2009; 2: 811-20.

(4.) Lefevre T, Kappetein AP, Wolner E, Nataf R Thomas M, Schachinger V, et al. One-year follow-up of the multi-centre European PARTNER transcatheter heart valve study. Eur Heart J 2011; 32: 148-57.

(5.) Gul M, Turen S, Surgit O, Aksu HU, Uslu N. Acute severe occlusion of the left main coronary artery following transcatheter aortic valve implantation. Anadolu Kardiyol Derg 2012; 12: 282-3.

Ahmet Cagri Aykan, Tayyar Gokdeniz, Mustafa Tarik Agac, Sukru Celik

Clinic of Cardiology, Ahi Evren Chest and Cardiovascular Surgery Education and Research Hospital, Trabzon-Turkey

Address for Correspandence/Yazisma Adresi: Dr. Ahmet Cagri Aykan Ahi Evren Gogus Kalp Damar Cerrahisi Egitim ve Arastirma Hastanesi, Trabzon-Turkiye Phone: 462 231 19 07 Fax: 462 231 04 83 E-mail: ahmetaykan@yahoo.com

Available Online Date/Cevrimici Yayin Tarihi: 16.11.2012

doi:10.5152/akd.20l3.024
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Title Annotation:Letters to the Editor/Editore Mektuplar
Author:Aykan, Ahmet Cagri; Gokdeniz, Tayyar; Agac, Mustafa Tarik; Celik, Sukru
Publication:The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)
Article Type:Letter to the editor
Date:Feb 1, 2013
Words:858
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