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Case Reports
. 2022 Jul 27:9:931595.
doi: 10.3389/fcvm.2022.931595. eCollection 2022.

Emergently Alteration of Procedural Strategy During Transcatheter Aortic Valve Replacement to Prevent Coronary Occlusion: A Case Report

Hanyi Dai  1   2 , Dao Zhou  1   2 , Jiaqi Fan  2 , Lihan Wang  2 , Abuduwufuer Yidilisi  1   2 , Gangjie Zhu  1   2 , Jubo Jiang  2 , Huajun Li  2 , Xianbao Liu  1   2 , Jian'an Wang  1   2
Affiliations
Case Reports

Emergently Alteration of Procedural Strategy During Transcatheter Aortic Valve Replacement to Prevent Coronary Occlusion: A Case Report

Hanyi Dai et al. Front Cardiovasc Med. .

Abstract

Background: Coronary occlusion is an uncommon but fatal complication of transcatheter aortic valve replacement (TAVR) with a poor prognosis.

Case presentation: A patient with symptomatic severe bicuspid aortic valve stenosis was admitted to a high-volume center specializing in transfemoral TAVR with self-expanding valves. No anatomical risk factors of coronary occlusion were identified on pre-procedural computed tomography analysis. The patient was scheduled for a transfemoral TAVR with a self-expanding valve. Balloon pre-dilatation prior to prosthesis implantation was routinely used for assessing the supra-annular structure and assessing the risk of coronary occlusion. Immediately after the tubular balloon inflation, fluoroscopy revealed that the right coronary artery was not visible, and the flow in the left coronary artery was reduced. The patient would be at high-risk of coronary occlusion if a long stent self-expanding valve was implanted. Therefore, our heart team decided to suspend the ongoing procedure. A transapical TAVR with a 23 mm J-valve was performed 3 days later. The prosthesis was deployed at a proper position without blocking the coronary ostia and the final fluoroscopy showed normal flow in bilateral coronary arteries with the same filling as preoperatively.

Discussion: Our successful case highlights the importance of a comprehensive assessment of coronary risk and a thorough understanding of the TAVR procedure for the heart team. A short-stent prosthesis is feasible for patients at high risk of coronary occlusion. Most importantly TAVR should be called off even if the catheter has been introduced when an extremely high risk of coronary obstruction is identified during the procedure and no solution can be found.

Keywords: aortic valve stenosis; emergent; pre-dilatation; procedural strategy; transcatheter aortic valve replacement.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

FIGURE 1
FIGURE 1
Pre-procedural computed tomography assessment of aortic root. (A) Annular perimeter: 73.1 mm and annular area: 414.1 mm2. (B) Left-, right- and non-sinuses of Valsalva dimensions: 31.6 mm * 30.7 mm * 30.7 mm. (C) Average sinotubular junction diameter: 27.6 mm. (D,E) The height of coronary arteries: 11 mm (left) and 14.1 mm (right). (F) The distance from the edge of the calcified nodule to right coronary ostium: 23 mm.
FIGURE 2
FIGURE 2
Intraoperative fluoroscopy. (A) Fluoroscopy showed bilateral patent coronary arteries before balloon pre-dilatation. (B) The right coronary artery was invisible and reduced blood flow in the left coronary artery during the balloon dilatation. (C) Fluoroscopy showed the patency of bilateral coronary arteries after J-valve deployment.
FIGURE 3
FIGURE 3
The J-Valve system design. The J-Valve aortic system consists of a self-expanding nitinol stent surrounded by three U-shaped anchor rings, with porcine aortic valve leaflets sutured inside. This draft was provided by the company JieCheng Medical Technology Co., Ltd., Suzhou, China.
See this image and copyright information in PMC

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