Concomitant percutaneous coronary intervention and transcatheter aortic valve replacement for aortic stenosis complicated with acute STEMI: a case report and literature review

Abstract

Aortic stenosis (AS) complicated with acute ST-segment elevation myocardial infarction (STEMI) is a life-threatening emergency with high mortality. A 75-year-old male patient attended the emergency department of Wuhan Asia Heart Hospital in December 2021 with chest pain for 2 days and exacerbation for 1 h. The electrocardiogram (ECG) indicated atrial fibrillation with rapid ventricular response and ST-segment depression. Echocardiography showed severe AS and mild/moderate aortic insufficiency. The patient refused coronary angiography and further invasive procedures and then requested discharge, but he had recurrent chest pain on the third day. The ECG showed an extensive anterior wall STEMI. During preoperative preparation, he suffered from cardiogenic shock (CS). Concomitant percutaneous coronary intervention (PCI) and transcatheter aortic valve replacement (TAVR) was performed, but he died of CS and multiple organ failure 4 days after surgery. Patients with AS and STEMI might be susceptible to CS during perioperative period of concomitant PCI and TAVR, which requires proactive prevention.

Keywords: acute ST-segment elevation myocardial infarction; aortic stenosis; cardiogenic shock; case report; percutaneous coronary intervention; transcatheter aortic valve replacement.

Figure 1

Coronary artery intervention treatment. The emergency coronary angiography results showed a left-dominant coronary artery, no severe stenosis in the right coronary artery (A), and no significant stenosis in the circumflex branch (B), but acute complete occlusion of the proximal segment of the left anterior descending branch (C). Angiography of the abdominal aorta-iliac artery bifurcation revealed diffuse narrowing of the left femoral artery (intravascular diameter <5 mm) and multiple ulcers and aneurysmal dilatation of the external iliac artery (D); selective angiography of the right iliac artery showed focal stenosis at the bifurcation of the right external-internal iliac artery (E).

Figure 2

TEE-measured virtual valve annulus diameter. The TEE-measured virtual aortic valve annulus diameter was 21.5 mm (A); the tricuspid aortic valve leaflets were severely calcified (B); color Doppler ultrasound showed mild-to-moderate aortic valve regurgitation (C).

Figure 3

TAVR process. After the 4.0 mm × 20 mm peripheral balloon was sent to the stenosis site of the external-internal iliac artery bifurcation through a 20Fr hydrophilic-coated guiding sheath, balloon angioplasty was performed with 6 atm to dilate the lesion vessel (A). The valve was quickly delivered to the aortic root through the catheter under mechanical chest compressions and was released after proper positioning (B). Aortic angiography showed no paravalvular leaks (C). Selective left coronary angiography indicated good coronary artery visualization (D). Selective right iliac artery angiography confirmed residual stenosis of less than 30% after balloon angioplasty of the stenosis site of the external-internal iliac artery bifurcation, with no local vascular complications such as dissection (E).