Figure 1. A-B) CT scan image of a calcified tricuspid aortic valve. C) Anomalous origin of the left ...

Figure 2. Cine coronary arteriography showing the anomalous origin of the left main coronary artery ...

Figure 3. Balloon sizing with a 20 mm x 40 mm balloon and aortic valvuloplasty.

Figure 4. A) Transcatheter aortic valve implantation of self-expanding valve. B) Final aortogram of ...

INTRODUCTION

Transcatheter aortic valve implantation (TAVI) consists of the transcatheter implantation of an aortic valve. This procedure is indicated in patients with symptomatic severe aortic stenosis. At the beginning it was used in inoperable patients, but in time its indication grew and now it is used in high-risk surgical patients,[1] and lately even in intermediate-risk surgical patients.[2] Recent studies confirm satisfactory results even in low-risk surgical patients.[3] TAVI is a widely used, well-tolerated procedure that has a high rate of success, few complications, and a short hospital stay.

Patients with low and anomalous origin of coronary ostia are particularly challenging because this condition can compromise the blood flow coming from coronary arteries after valve implantation. Several techniques can be used to prevent this complication like securing flow inside the coronary arteries with a guidewire or a stent, using the balloon sizing method, selecting the right valve, and other.[4]

This is the case report of a woman with severe aortic stenosis who was eligible for TAVI with low and anomalous origin of coronary arteries.

OBJECTIVES

Case report of a TAVI procedure performed in a high-surgical risk female patient with symptomatic severe aortic stenosis and low and anomalous origin of coronary arteries.

CASE REPORT

This is the case of an 88-year-old woman with a past medical history of arterial hypertension, dyslipidemia, chronic anemia, and breast cancer at the age of 63 that was treated with radio and chemotherapy. The physical examination performed at the cardiology unit revealed clinical signs of dyspnea (functional class II/III). Also, the presence of an intensity 5/6 aortic systolic heart murmur with reduced R2 radiating towards the carotid arteries.

The following additional imaging modalities were performed:

• Electrocardiogram (ECG): RS, PR interval, 0.20 seconds; HR, 70 bpm, left ventricular overload (LVO).
• Doppler echocardiogram: severe aortic stenosis, gradient peak of 75 mmHg, mean gradient of 45 mmHg, AVA, 0.71; LVEF, 65% without motility disorders.
• Computed tomography (CT) scan: heavily calcified tricuspid aortic valve, valve area, 357.4 mm2; valvular perimeter, 67.8 mm; valvular calcification score, 1777; sinotubular junction perimeter, 25.5 mm; sinuses of Valsalva, 24.9 mm. Preserved bilateral femoral arterial accesses. The images confirm the presence of an anomalous origin of the left main coronary artery from the right sinus. Height of right coronary ostium, 9 mm; (Fig. 1).
• Cine coronary arteriography: Anomalous origin of the left main coronary artery from the right sinus with retroaortic path. Coronary artery without significant injuries (Fig. 2).
• Doppler echocardiography of neck vessels: patent carotid and vertebral arteries without significant injuries.
• Laboratory: Hematocrit, 35; Hb, 12; uremia, 25; creatinine levels, 0.68; platelet count, 273 000.
• Edmonton Frail Scale score 6-7 (vulnerable).
• STS score (8), and EuroSCORE II (3.43%)

  After discussing the case with the heart team, it was decided to perform TAVI. The right femoral access was used followed by the pre-closure technique after transcatheter implantation. Right radial access was used to place a pigtail catheter inside the noncoronary sinus to assess the positioning of the valve. The AL1 guide catheter was advanced from the femoral access towards the valvular plane. The valve was crossed using a 0.035 in straight guidewire. The pigtail catheter was used for exchange purposes. Then, a 0.035 in Safari high-support extra small guidewire was advanced and the pigtail catheter was removed. Afterwards, the balloon sizing method was used with aortogram guidance with a 20 mm x 40 mm balloon and aortic valvuloplasty was performed with cardiac pacing from the guidewire into the LV (Fig. 3). The transcatheter aortic valve ACURATE neo™ - Aortic Valve System (Boston Scientific, United States) was eventually implanted (Fig. 4).

  The bedside Doppler echocardiography performed revealed the correct positioning of the valve without, no traces of paravalvular leak, and a peak gradient of 10 mmHg. Also, pressure pullbacks with the pigtail catheter were performed with pullback from the LV towards the aorta without a significant gradient. Finally, a thoracic aortogram confirmed the presence of patent coronary arteries. The procedure ended when catheters, guidewires, introducer sheaths, and percutaneous vascular closure devices (ProGlide, Abbott, United States) were pulled back from the femoral access.

  The patient’s progression was favorable, and she was immediately referred to the hospital coronary unit. She was discharged 48 hours after the procedure. AAS, and clopidogrel were prescribed at discharge. The patient remained asymptomatic at the 3-month follow-up performed outpatiently. The control Doppler echocardiography confirmed the proper positioning of the aortic valve without any significant gradients or traces of paravalvular leak.

  DISCUSSION

  TAVI is a minimally invasive transcatheter procedure for aortic valve implantation in patients with symptomatic severe aortic stenosis. Although TAVI is well-tolerated, patients with low origin of coronary ostia are tremendously challenging. This condition can lead to the occlusion of native coronary arteries during the procedure, a serious complication with high morbidity and mortality rates (40.9% after 30 days). In this case, the mechanism of coronary occlusion (CO) would be the occlusion of coronary ostium due to valves that are poorly positioned—high apposition—or valves properly positioned in patients with a low origin of coronary ostium. Other mechanisms of occlusion are displaced heavily calcified leaflets towards the coronary ostium, and aortic dissection, among others.[5]

  The risk factors predisposing to coronary occlusion after TAVI are the low origin of left main coronary artery (> 12 mm), sinus of Valsalva > 30 mm, valve-in-valve procedure, VTC distances > 4 mm (virtual distance between the valve to be implanted and the origin of coronary ostium), severe calcification with a large calcium node in the left cusp (bicuspid), extreme oversizing, self-expanding valve, lack of CABG, and feminine sex.[6]

  Several techniques have been described to prevent coronary artery occlusion. The balloon sizing method is one of them. It consists of performing an aortic valvuloplasty before valve implantation to confirm that leaflet displacement after balloon inflation has not occluded the coronary ostia.[7]

  Despite all this, it is essential to conduct a thorough study using a multislice CT scan with correct measurements of the origin of coronary ostia, the perimeter and diameter of the annulus, the diameter of the sinuses of Valsalva, and the sinotubular junction to determine the type and size of the transcatheter valve that will eventually be implanted. There are other techniques that can be used to prevent such occlusion from happening during the procedure. One of them is the preemptive cardiac catheterization of coronary artery with a guide catheter, the distal advance of a 0.014 in guidewire followed by stent deployment into the coronary artery while waiting for implantation in case of coronary occlusion post-TAVI.[8]

  Finally, in this case the ACURATE neo self-expanding valve was used. A valve that can be used with a distance between the ostium coronary ostium and the annular plane ≥ 8 mm, and with a favorable distribution of leaflet calcification. This is possible because the stents of the upper crown attach to the native aortic valve leaflets keeping them away from coronary ostia. Also, the configuration of the stents guarantees easy coronary access for future coronary procedures.[9,10]

  CONCLUSION

  TAVI in patients with low origin of coronary ostia is tremendously challenging. Previous planning is essential for procedural success. It requires a proper selection of the valve, and use of coadjuvant methods like the balloon sizing method to reduce any complications that may occur.

  Conflicts of interest: None reported.

  Funding: None whatsoever.

  Informed consent: The patient signed the corresponding written informed consent form to participate in this study and authorized us to publish her data.

  REFERENCES

  1. Smith C, Leon M, Mack M, et al. Transcatheter versus Surgical Aortic-Valve Replacement in High-Risk Patients. N Engl J Med 2011;364(23):2187-98.
  2. Leon M, Smith C, Mack M, et al. Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk Patients. N Engl J Med 2016;374(17):1609-20.
  3. Mack M, Leon M, Thourani V, et al. Transcatheter Aortic-Valve Replacement with a Balloon-Expandable Valve in Low-Risk Patients. N Engl J Med 2019;380(18):1695-1705.
  4. Barbanti M, Sgroi C, Immè S, et al. Usefulness of contrast injection during balloon aortic valvuloplasty before transcatheter aortic valve replacement: a pilot study. EuroIntervention 2014;10(2):241-7.
  5. Okuyama K, Jilaihawi H, Makkar RR. Leaflet length and left main coronary artery occlusion following transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2013;82(5):E754-759.
  6. Ribeiro HB, Webb JG, Makkar RR, et al. Predictive factors, management, and clinical outcomes of coronary obstruction following transcatheter aortic valve implantation: insights from a large multicenter registry. J Am Coll Cardiol 2013;62(17):1552-62.
  7. Krishnaswamy A, Kapadia SR. Optimizing Valve Sizing in Balloon-Expandable Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2018;11(17):1706-09.
  8. Yamamoto M, Shimura T, Kano S, et al. Impact of preparatory coronary protection in patients at high anatomical risk of acute coronary obstruction during transcatheter aortic valve implantation. Int J Cardiol 2016;217:58-63.
  9. Möllmann H, Hengstenberg C, Hilker M, et al. Real-world experience using the ACURATE neo prosthesis: 30-day outcomes of 1,000 patients enrolled in the SAVI TF registry. EuroIntervention 2018;13(15):e1764-e1770.
  10. Kim WK, Hengstenberg C, Hilker M, et al. Transcatheter aortic valve implantation with the ACURATE neo valve: indications, procedural aspects and clinical outcomes. EuroIntervention 2020;15(18):e1571-e1579.

1. Smith C, Leon M, Mack M, et al. Transcatheter versus Surgical Aortic-Valve Replacement in High-Risk Patients. N Engl J Med 2011;364(23):2187-98.

2. Leon M, Smith C, Mack M, et al. Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk Patients. N Engl J Med 2016;374(17):1609-20.

3. Mack M, Leon M, Thourani V, et al. Transcatheter Aortic-Valve Replacement with a Balloon-Expandable Valve in Low-Risk Patients. N Engl J Med 2019;380(18):1695-1705.

4. Barbanti M, Sgroi C, Immè S, et al. Usefulness of contrast injection during balloon aortic valvuloplasty before transcatheter aortic valve replacement: a pilot study. EuroIntervention 2014;10(2):241-7.

5. Okuyama K, Jilaihawi H, Makkar RR. Leaflet length and left main coronary artery occlusion following transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2013;82(5):E754-759.

6. Ribeiro HB, Webb JG, Makkar RR, et al. Predictive factors, management, and clinical outcomes of coronary obstruction following transcatheter aortic valve implantation: insights from a large multicenter registry. J Am Coll Cardiol 2013;62(17):1552-62.

7. Krishnaswamy A, Kapadia SR. Optimizing Valve Sizing in Balloon-Expandable Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2018;11(17):1706-09.

8. Yamamoto M, Shimura T, Kano S, et al. Impact of preparatory coronary protection in patients at high anatomical risk of acute coronary obstruction during transcatheter aortic valve implantation. Int J Cardiol 2016;217:58-63.

9. Möllmann H, Hengstenberg C, Hilker M, et al. Real-world experience using the ACURATE neo prosthesis: 30-day outcomes of 1,000 patients enrolled in the SAVI TF registry. EuroIntervention 2018;13(15):e1764-e1770.

10. Kim WK, Hengstenberg C, Hilker M, et al. Transcatheter aortic valve implantation with the ACURATE neo valve: indications, procedural aspects and clinical outcomes. EuroIntervention 2020;15(18):e1571-e1579.

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TAVI in patient with low and anomalous origin of left main coronary artery. Case report

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