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Case Reports
. 2024 Nov 26;8(12):ytae622.
doi: 10.1093/ehjcr/ytae622. eCollection 2024 Dec.

Balloon aortic valvuloplasty with simultaneous aortic root injection: a case report of an adjunctive strategy to computed tomography for predicting coronary obstruction in transcatheter aortic valve-in-transcatheter aortic valve procedures

Tetsuro Shimura  1 , Masanori Yamamoto  1   2   3 , Hitoshi Matsuo  1
Affiliations
Case Reports

Balloon aortic valvuloplasty with simultaneous aortic root injection: a case report of an adjunctive strategy to computed tomography for predicting coronary obstruction in transcatheter aortic valve-in-transcatheter aortic valve procedures

Tetsuro Shimura et al. Eur Heart J Case Rep. .

Abstract

Background: Computed tomography (CT) assessment is the standard for predicting coronary obstruction (CO) caused by sinus sequestration (SS) during transcatheter aortic valve (TAV) implantation in degenerated TAV (TAV-in-TAV) procedure, but it may not always be accurate. This report describes a prediction method for CO by using balloon aortic valvuloplasty (BAV) during TAV-in-TAV.

Case summary: An 87-year-old woman with a history of balloon-expandable transcatheter heart valve (BE-THV) implantation 7 years prior was admitted with worsening dyspnoea. Echocardiography revealed severe THV deterioration, and CT confirmed calcium proliferation in the THV. Our heart team decided to perform a TAV-in-TAV procedure using a 23-mm BE-THV. Preoperative CT imaging indicated an intermediate risk of CO. To evaluate CO risk more precisely, the top of a 20-mm balloon was positioned near the top of a BE-THV stent and inflated, followed by simultaneous aortic root injection (SARI). During SARI, contrast flowed into both coronary arteries, predicting a low risk of CO. Based on these findings, TAV-in-TAV was performed without coronary protection. The procedure was completed successfully without CO. After the procedure, the patient's symptoms improved, and echocardiography showed normal valve function. She was discharged without complications and remains under outpatient follow-up care.

Discussion: The diagnostic method for predicting CO using BAV with SARI could serve as a valuable adjunctive diagnostic tool in patients with an intermediate or high risk of SS anatomy after TAV-in-TAV. In such cases, this method may provide additional insights concerning precise CO risk and the indication of leaflet modification technique during TAV-in-TAV.

Keywords: Balloon aortic valvuloplasty; Case report; Coronary obstruction; Redo TAVI; Simultaneous aortic root injection; Sinus sequestration; TAV-in-TAV.

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Conflict of interest statement

Conflict of interest: M.Y. is a clinical proctor at Edwards Lifesciences, Medtronic, Abbott, and Boston Scientific and received speaker fees from Edwards Lifesciences, Medtronic, Abbott, Boston Scientific, Daiichi Sankyo, and Kaneka Medics Corporation. T.S. is a clinical proctor at Abbott and received speaker fees from Edwards Lifesciences, Medtronic, Abbott, Boston Scientific, Daiichi Sankyo, and Kaneka Medics Corporation. The other author has nothing to disclose.

Figures

Figure 1
Figure 1
Contrast computed tomography revealed calcified transcatheter heart valve leaflets and commissures (A–C). The transcatheter heart valve area at inflow was 387 mm2  (D). The transcatheter heart valve area at mid-portion was 339 mm2  (E). The transcatheter heart valve area at outflow was 361 mm2  (F). The minimum and maximum sino-tubular junction diameters were 24.7 and 25.6 mm (G), respectively. Distances to the left and right coronary arteries were 3.9 and 4.6 mm, respectively (H and I). The distance of the lowest ostium of the left and right coronary arteries and the bottom of transcatheter heart valve were 14.5 and 15.0 mm, respectively (J and K). The height of transcatheter heart valve was 20.5 mm (L).
Figure 2
Figure 2
A detailed inflation size chart for the SAPIEN 3 ULTRA RESILIA and dedicated balloon aortic valvuloplasty balloon. The chart outlines the expansion area for each device in 0.5 mL increments, ranging from −4 to +4 mL.
Figure 3
Figure 3
Schema of balloon aortic valvuloplasty with its top aligned at the top of the transcatheter heart valve (A). Coronary flow was visualized during balloon aortic valvuloplasty with its top positioned near the top of the transcatheter heart valve with simultaneous aortic root injection (B). Ballooning at the usual position during transcatheter aortic valve implantation can obstruct coronary flow (C). The ballooning for transcatheter aortic valve implantation temporarily obstructed coronary flow (D). Coronary flow is expected to resume after transcatheter aortic valve-in-transcatheter aortic valve (E). Good coronary flow is observed (F).
None
See this image and copyright information in PMC

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