Successful percutaneous coronary intervention after implantation of a CoreValve percutaneous aortic valve

Background: The association between aortic valve disease and coronary atherosclerosis is common. In the recent era of percutaneous aortic valve replacement (PAVR), there is little experience with coronary artery intervention after valve implantation. Case report: To our knowledge, this is the first case of successful percutaneous coronary intervention after implantation of a CoreValve percutaneous aortic valve. We report a case of a 79‐year‐old female patient who underwent successful coronary artery intervention few months after a CoreValve's percutaneous implantation for severe aortic valve stenosis. Verifying the position of the used wires (crossing from inside the self expanding frame) is of utmost importance before proceeding to coronary intervention. In this case, crossing the aortic valve, coronary angiography, and multivessel stenting were successfully performed. Conclusion: Percutaneous coronary intervention in patients with previous CoreValve is feasible and safe. © 2008 Wiley‐Liss, Inc.     

Percutaneous coronary intervention and aortic valve implantation in a patient with breast cancer

We present a case of a 70 year-old female with severe aortic stenosis, multivessel coronary artery disease and breast cancer who successfully underwent complex percutaneous coronary revascularisation, transapical aortic valve implantation and mastectomy.     

Ad-hoc percutaneous coronary intervention and transcatheter aortic valve implantation as a combined transfemoral procedure

Coronary artery disease has been reported in more than 50% of patients with severe aortic stenosis above the age of 70 years. Combined surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG) is associated with a higher operative risk. Concomitant coronary artery disease also increases the procedural risk of transcatheter aortic valve implantation (TAVI), and hence, a combined strategy for treating both entities needs to be carefully considered. Data regarding TAVI and percutaneous coronary intervention (PCI) as a combined percutaneous procedure are scarce. We report the case of an 84-year-old woman who presented with non-ST segment elevation myocardial infarction and impending pulmonary edema who was diagnosed with severe aortic stenosis and two-vessel coronary artery disease. Because of an elevated logistic Euroscore of 25% and her unstable presentation, percutaneous coronary revascularization and TAVI were successfully performed in a combined percutaneous transfemoral procedure. She had a smooth recovery and rehabilitation period with significant improvement in her symptoms and functional capacity. Thirty-day follow-up, including transthoracic echocardiography and cardiac magnetic resonance imaging, showed a well-functioning prosthetic valve and no signs of residual myocardial ischemia. We therefore conclude that combined PCI and TAVI is feasible and can be associated with good clinical outcomes in selected cases. Further data and experience are needed to evaluate this strategy.     

Aortic valvuloplasty associated with coronary angioplasty. Description of a case

The authors report the case of a 57 year-old man with severe calcific aortic stenosis and single vessel coronary artery disease, symptomatic of angina pectoris, who refused surgical therapy and was treated with combined percutaneous aortic valvuloplasty and coronary angioplasty as a single procedure. Valvuloplasty was performed initially, and the calculated aortic valve area increased from 0.75 to 1.27 cm2. Subsequently, a 75% proximal right coronary artery stenosis was dilated to 20%. Two months later, at follow-up the patient was asymptomatic and the Doppler-determined aortic valve area was 1.01 cm2.     

A case of severe aortic stenosis with severe coronary artery disease that was successfully treated by balloon aortic valvuloplasty and percutaneous coronary intervention

We describe an 85-year-old woman with severe aortic stenosis, who also had severe coronary artery disease. She suffered from dyspnea on exertion and frequent syncope. Echocardiography revealed an immobile and heavily calcified aortic valve, and coronary angiography revealed two-vessel disease including chronic total occlusion. Open-heart surgery was refused and she was referred to our department. She underwent percutaneous coronary intervention (PCI) for the right coronary artery and left anterior descending artery. Following PCI, percutaneous balloon aortic valvuloplasty (BAV) was performed on the same day. We chose balloons of 15 × 60 mm, 18 × 60 mm, and 20 × 60 mm, respectively. Improvement in the mean aortic valve pressure gradient (PG) and calculated aortic valve area (mean PG 48-23 mmHg, 0.8-1.2 cm(2), respectively) was observed after the final balloon dilatation. No significant complications occurred. The combination of BAV with PCI may be a useful treatment for relief of the associated symptoms of severe aortic stenosis and coronary artery disease, though it does not improve the long-term prognosis.     

Percutaneous coronary intervention of a saphenous vein graft ostial stenosis in a patient with Bentall procedure

Composite graft replacement of the aortic root and coronary reimplantation with or without coronary artery bypass surgery is the standard treatment for a variety of aortic root pathologies. Previously, percutaneous coronary intervention of either reimplanted coronary arteries or left/right coronary artery through cabrol graft has been described in post-Bentall patients. We describe percutaneous coronary intervention of a saphenous vein graft ostial stenosis in a patient with previous Bentall procedure and a vein graft to right coronary artery, which was complex and challenging.     

Coronary Angiography and Percutaneous Coronary Intervention After Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) has revolutionized the management of patients with symptomatic severe aortic stenosis, and indications are expanding towards treating younger patients with lower-risk profiles. Given the progressive nature of coronary artery disease and its high prevalence in those with severe aortic stenosis, coronary angiography and percutaneous coronary intervention will become increasingly necessary in patients after TAVR. There are some data suggesting that there are technical difficulties with coronary re-engagement, particularly in patients with self-expanding valves that, by design, extend above the coronary ostia. The authors review the challenges of coronary angiography and percutaneous coronary intervention post-TAVR and examine the geometric interactions between currently approved transcatheter aortic valves and coronary ostia, while providing a practical guide on how to manage these potentially complex situations.     

Feasibility of complex coronary intervention in combination with percutaneous aortic valve implantation in patients with aortic stenosis using percutaneous left ventricular assist device (TandemHeart®)

Coronary atherosclerosis is a common finding in patients with severe aortic stenosis. Indeed, aortic stenosis is associated with risk factors similar those of coronary atherosclerosis such as older age, hypertension, diabetes, hypercholesterolemia and smoking. In light of the evolution of percutaneous aortic valve implantation (PAVI) and ongoing improvements in techniques of PCI, a combined approach using PCI and PAVI can be proposed for patients with complex coronary artery and aortic valve disease. This report describes the feasibility of the combination of percutaneous coronary intervention and percutaneous aortic valve implantation with peripheral left ventricular assist device (TandemHeart) support in 3 elderly patients with complex coronary altery disease and aortic stenosis considered too high risk for conventional surgical therapy. © 2009 Wiley‐Liss, Inc.     

Combined percutaneous balloon dilatation of the aortic valve and coronary angioplasty

A 75 year old man with severe angina caused by aortic stenosis and coronary artery disease was considered to be unsuitable for cardiac surgery after the recent removal of a bronchial carcinoma. Combined percutaneous balloon dilatation of the aortic valve and right coronary angioplasty considerably ameliorated the patient's angina.     

Combined percutaneous balloon dilatation of the aortic valve and coronary angioplasty.

A 75 year old man with severe angina caused by aortic stenosis and coronary artery disease was considered to be unsuitable for cardiac surgery after the recent removal of a bronchial carcinoma. Combined percutaneous balloon dilatation of the aortic valve and right coronary angioplasty considerably ameliorated the patient's angina.     

Left Main Coronary Artery Obstruction by Dislodged Native-Valve Calculus after Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement can be an effective, reliable treatment for severe aortic stenosis in surgically high-risk or ineligible patients. However, various sequelae like coronary artery obstruction can occur, not only in the long term, but also immediately after the procedure. We present the case of a 78-year-old woman whose left main coronary artery became obstructed with calculus 2 hours after the transfemoral implantation of an Edwards Sapien XT aortic valve. Despite percutaneous coronary intervention in that artery, the patient died. This case reminds us that early recognition of acute coronary obstruction and prompt intervention are crucial in patients with aortic stenosis who have undergone transcatheter aortic valve replacement.     

Novel approach to stenting the left anterior descending coronary artery through a retrograde approach via the left internal mammary artery graft in a patient with occlusion of the coronary ostium from a prior aortic valve replacement

Total occlusion of both coronary ostia is a rare and potentially life-threatening complication following surgical aortic valve replacement. This report presents a case of a patient with known total occlusion of both coronary artery ostia following combined coronary artery bypass graft surgery and aortic valve replacement who underwent successful percutaneous coronary intervention through a retrograde approach.     

Palliative combined percutaneous balloon aortic valvuloplasty and unprotected left main stenting in end stage renal disease

With the aging population and high prevalence of atherosclerosis, an increasing number of patients presenting with heart failure and angina are found to have severe coronary artery disease and severe valvular disease. These patients tend to have multiple co-morbidities such as end stage renal disease and are considered high-risk for surgery. In patients with severe coronary artery disease, severe aortic stenosis, and heart failure with depressed left ventricular systolic function, the options are limited as they are not usually offered surgery, but palliative percutaneous high-risk procedures might be a viable alternative.Though long term results after balloon aortic valvuolpasty are not promising, there is a role for these procedures in high-risk inoperable patients for either palliation or as a bridge to surgery. Unprotected left main percutaneous interventions are also feasible with low complication rates. This review provides mounting evidence that it is reasonable to perform combined palliative balloon aortic valvuolpasty and high-risk coronary artery stenting in certain inoperable patients. An illustrative case is presented that extends the findings of the current literature and demonstrates that combined balloon aortic valvuolpasty and left main stenting could be a safe and effective alternative in the setting of heart failure, left ventricular dysfunction, and end stage renal disease.     

Percutaneous balloon valvuloplasty and coronary angioplasty for the treatment of calcific aortic stenosis and obstructive coronary artery disease in an elderly patient

An 81-year-old man with severe calcific aortic stenosis and coronary artery disease who refused surgical therapy was treated with sequential percutaneous balloon aortic valvuloplasty (PBAV) and percutaneous transluminal angioplasty. Before percutaneous balloon valvuloplasty, the mean aortic gradient was 76 mmHg, and the aortic valve area was .45 cm2. The aortic valve was dilated using 15-mm and 18-mm balloons. The mean gradient decreased to 40 mmHG, and the aortic valve area increased to .62 cm2. Percutaneous transluminal coronary angioplasty (PTCA) was performed 2 weeks later, and an 85% proximal left circumflex stenosis was successfully dilated to 20%. No complications were noted during either procedure. At 6-month follow-up, the patient had returned to normal activities and was asymptomatic. Thus, combined therapy with PBAV and PTCA is technically feasible in selected elderly patients with calcific aortic stenosis and anatomically suitable coronary artery disease. This nonsurgical therapeutic approach may be useful in the treatment of selected patients who refuse or who are deferred from cardiac surgery.     

Aortic and coronary artery dissection during percutaneous coronary intervention: a case report and review article

Coronary artery dissection is an uncommon but potentially serious complication in percutaneous coronary interventions. We treated a 53-year-old female patient with right coronary spasm, which was misdiagnosed as a coronary lesion. The coronary spasm resolved with nitrate administration, but proximal coronary dissection developed during angiography. It progressed anterograde and led to inferior myocardial infarction and severe hemodynamic instability due to right coronary artery occlusion. Percutaneous intervention failed, and it was determined that coronary dissection progressed retrograde, across the truncus of the aorta. Ascending aortic grafting and coronary bypass surgery were performed. The patient recovered and was discharged after 10 days. Close cardiothoracic observation is mandatory in patient evaluation and management.     

Endovascular repair of severe aortic coarctation,transcatheter aortic valve replacement for severe aortic stenosis,and percutaneous coronary intervention in an elderly patient with long term follow-up

To the best of our knowledge, there have not been any reports of total transcatheter approach including stenting of severe coarctation of the aorta (CoA), transcatheter aortic valve replacement (TAVR) for concomitant severe aortic valve stenosis, and percutaneous coronary intervention (PCI) to treat significant coronary artery disease in a single patient. We report a 70-year-old female, who presented with uncontrolled hypertension and acute decompensated heart failure (ADHF) and was found to have severe CoA, severe bicuspid aortic valve (BAV) stenosis, and significant proximal left anterior descending (LAD) coronary artery disease. In a multidisciplinary heart team meeting, we decided to perform an endovascular repair of both cardiac and vascular pathologies using a two-stage approach due to the significant comorbidities; mainly uncontrolled hypertension, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and severe calcifications of the ascending aorta. The procedures were successfully performed and the patient was asymptomatic 30?months later at follow-up and was without any significant gradients across the coarctation or the aortic valve.     

Coarctation of aorta with complete aortic occlusion

Survival to advanced age is exceptional in patients with unrepaired aortic coarctation. We report the case of an 81-year-old man with aortic coarctation and total occlusion who was otherwise asymptomatic. Coarctation was suspected when a femoral-radial pulse delay was noted during his routine physical examination. A 70-mmHg systolic blood pressure gradient between the upper and lower extremities was detected. Subsequent magnetic resonance angiography, aortography, and coronary angiography revealed severe coarctation of the aorta, well-developed collateral vessels, and severe coronary artery disease. A staged percutaneous coronary intervention procedure was performed and the coarctation was managed conservatively with antihypertensive medication.     

Management of significant left main coronary disease before and after trans‐apical transcatheter aortic valve replacement in a patient with severe and complex arterial disease

We report the case of an 81‐year‐old woman with symptomatic severe aortic stenosis, extremely significant peripheral arterial disease, and obstructive coronary artery disease who underwent percutaneous coronary intervention via a transaxillary conduit immediately before a trans‐apical transcatheter aortic valve replacement performed with a transfemoral device. After deployment of the transcatheter heart valve, there was a left main coronary obstruction and the patient required an emergent PCI. This multifaceted case clearly underlines the importance of a well functioning heart team including the interventional cardiologist, the cardiovascular surgeon, and the echocardiographer. © 2013 Wiley Periodicals, Inc.     

Primary percutaneous coronary intervention for ST-elevation myocardial infarction in a patient with a single coronary artery arising from the right aortic sinus

We report the first case of primary percutaneous coronary intervention (PPCI) in a patient with a single coronary artery arising from the right aortic sinus. With the increasing availability of PPCI, more patients with coronary artery anomalies will undergo this procedure. This report highlights both the feasibility and safety of PPCI in patients with even the rarest of coronary artery anomalies.     

An isolated single L-I type coronary artery with severe LAD lesions treated by transradial PCI

Cases of coronary arteries with anomalous aortic origin are rare. An isolated single coronary artery is a congenital anomaly occurring in approximately 0.024-0.066% of the population. Atherosclerosis of these arteries is not infrequent with potentially severe consequences, but interventional procedures are rarely performed. We report an acute coronary syndrome case due to a subtotal paraostial left anterior descending (LAD) occlusion of a single L-I type coronary artery. Another severe stenosis was also present at mid-LAD. The patient was successfully treated with transradial percutaneous coronary intervention (PCI). Our case shows that when the anatomy is suitable, complex PCI can be performed successfully in single coronary arteries.