Coronary physiology to guide treatment of coronary artery disease in a patient with severe aortic valve stenosis: friend or foe? A case report

Abstract

Background: Severe aortic valve stenosis (AS) is the most frequent valve pathology in the developed world requiring intervention. Due to common factors in pathogenesis, patients with AS frequently have concomitant coronary artery disease (CAD). Determining the relative contribution of each component to the disease state is not easy as there is much overlap in complaints. Moreover, severe AS interferes with the haemodynamic assessment of intermediate coronary lesions.

Case summary: In this case report we describe the presentation and management of an 84-year-old patient, with a severely degenerated aortic valve bioprosthesis and an intermediate coronary artery lesion, presenting with acute decompensated heart failure and chest pain. Initial invasive haemodynamic assessment of the coronary lesion provided challenging findings and a second catheterization and intervention was needed to free the patient from his chest pain.

Discussion: Optimal assessment and treatment of CAD before valve replacement are controversial. Aortic valve stenosis on itself can lead to subendocardial ischaemia with subsequent angina pectoris. Simultaneously, AS can significantly affect coronary haemodynamics, hereby interfering with intra-coronary haemodynamic assessment of co-existing coronary lesions. Currently used coronary physiological indices are not validated in the AS population and valve replacement has variable effects on the fractional flow reserve and commonly used resting indices, such as the resting full-cycle ratio. Further research on this topic is needed and an overview of currently running studies that will advance this field significantly is provided.

Keywords: Aortic valve stenosis; Case report; Coronary artery disease; Coronary physiology; Coronary revascularization; Microvascular function; Transcatheter aortic valve implantation.

Figure 1

Angiographic image of the coronary stenosis. (A) The angiographic image of the right coronary artery stenosis through an left anterior oblique view. The stenosis is marked by the white arrow. (B) The angiographic image of the right coronary artery after the placement of two drug eluting stents.

Figure 2

Changes in coronary haemodynamics after transcatheter aortic valve implantation. The top panel shows the angiographic view of the degenerated aortic valve and the coronary haemodynamic measurements during the valve work-up. The lower panel shows the angiographic view of the transcatheter aortic valve implantation prosthesis in the biological valve and the haemodynamic measurements of the same right coronary artery lesion 6 months after the valve procedure. AV, aortic valve; (PB-) CFR (norm), (pressure-bound) coronary flow reserve (normalized); IMR (norm), index of microvascular resistance (normalized); Pa, proximal coronary pressure; Pd, distal coronary pressure; RRR, resistive reserve ratio; TAVI, transcatheter aortic valve implantation.

Figure 3

Non-invasive ischaemia testing. The figure shows the results of the myocardial perfusion single photon-emission computed tomography. Regadenoson was used to induce a stress response. A reversible perfusion defect of 15% can be seen in the inferior and inferolateral wall corresponding with the right coronary artery perfusion territory. On the left the perfusion defect is marked with white arrows. On the right the perfusion defect area is traced with white lines. The perfusion defect has an summed stress score of 14 and summed defect score of 6, a delta (Δ) extent of 12% and a delta (Δ) TPD of 9%. SDS, summed defect score; SPECT, single photon-emission computed tomography; SRS, summed rest score; SSS, summed stress score; TPD, total perfusion deficit score.