Iatrogenic left main coronary artery stenosis following aortic valve replacement

A case of severe iatrogenic fibrous left main coronary arterystenosis following aortic valve replacement (Hall-Kaster prosthesis)is documented clinically, angiographically and histologically.Reported histological data of this rare complication of valvereplacement are reviewed. The onset of ischaemic symptoms inthe first six months after valve replacement is highly suggestiveof iatrogenic coronary artery stenosis, and urgent coronaryangiography is recommended.     

Iatrogenic right coronary artery stenosis resulting from surgical tricuspid valve replacement

Iatrogenic injury to the right coronary artery (RCA) is a rare complication of tricuspid valve surgery. We herein describe the first‐ever report of RCA injury related to tricuspid valve replacement surgery. A 38‐year‐old man with recurrent tricuspid endocarditis underwent redo tricuspid valve replacement by means of a minimally invasive right thoracotomy with a 32‐mm St. Jude bioprosthetic valve. His post‐operative course was complicated by pulseless ventricular tachycardia requiring CPR and defibrillation. Cardiac catheterization revealed a “kinked” stenotic distal RCA. The lesion was noted to be flow limiting by fractional flow reserve and was treated with two everolimus‐eluting stents. The RCA runs in the atrioventricular groove and is susceptible to injury especially in the region of the posterior leaflet of the tricuspid valve, where the relationship of the tricuspid annulus to the RCA is most intimate. Repair of surgically induced coronary stenosis can be accomplished with percutaneous intervention. © 2014 Wiley Periodicals, Inc.     

Aortic valve replacement for patients with mild to moderate aortic stenosis undergoing coronary artery bypass surgery

Aortic valve replacement (AVR) is not normally recommended in asymptomatic patients, even if aortic stenosis is severe. However, as the population ages, an increasing number of patients with mild or moderate aortic stenosis will require coronary artery bypass grafting (CABG). In these cases, risk of "prophylactic" AVR needs to be weighed against risks of subsequent worsening of the mildly or moderately diseased aortic valve. If unoperated, aortic stenosis will worsen at an average of 6-8 mmHg per year (-0.1 cm2/year valve area), and one-quarter of such patients will require late AVR with a high operative mortality (14-24%). If AVR is performed at the time of CABG, operative risk is increased only slightly (from 1-3% to 2-6%), as are late mortality (1-2% per year) and morbidity (1-2% per year), mainly from hemorrhagic complications. Intrinsic gradients of most prosthetic valves are sufficiently low that even patients with low aortic valve gradients are likely to derive hemodynamic benefit from AVR. Thus, if there is a measurable (>20-25 mmHg) gradient across the aortic valve in a patient who requires CABG, the patient is at considerable risk for developing symptomatic aortic stenosis prior to reaching the end of expected benefit from CABG; in this case AVR should be considered. It may be reasonable in patients with very mild gradients (<25 mmHg) to defer aortic valve surgery; however, it should be noted that aortic stenosis progression is generally more rapid when the initial gradient is small.     

The impact of mitral stenosis on outcomes of aortic valve stenosis patient undergoing surgical aortic valve replacement or transcatheter aortic valve replacement

Background

The concomitant presence of mitral stenosis (MS) in the setting of symptomatic aortic stenosis represent a clinical challenge. Little is known regarding the outcome of mitral stenosis (MS) patients undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). Therefore, we sought to study the outcome of MS patients undergoing aortic valve replacement (AVR).

Method

Using weighted data from the National Inpatient Sample (NIS) database between 2011 and 2014, we identified patients who were diagnosed with MS. Patients who had undergone TAVR as a primary procedure were identified and compared to patients who had SAVR. Univariate and multivariate logistic regression analysis were performed for the outcomes of in‐hospital mortality, length of stay (LOS), blood transfusion, postprocedural hemorrhage, vascular, cardiac and respiratory complications, permanent pacemaker placement (PPM), postprocedural stroke, acute kidney injury (AKI), and discharge to an outside facility.

Results

A total of 4524 patients were diagnosed with MS, of which 552 (12.2%) had TAVR and 3972 (87.8%) had SAVR. TAVR patients were older (79.9 vs 70.0) with more females (67.4% vs 60.0%) and African American patients (7.7% vs 7.1%) (P < 0.001). In addition, the TAVR group had more comorbidities compared to SAVR in term of coronary artery disease (CAD), congestive heart failure (CHF), chronic lung disease, hypertension (HTN), chronic kidney disease (CKD), and peripheral vascular disease (PVD) (P < 0.001 for all). Using Multivariate logistic regression, and after adjusting for potential risk factors, TAVR patients had lower in‐hospital mortality (7.9% vs 8.1% adjusted Odds Ratio [aOR], 0.615; 95% confidence interval [CI], 0.392–0.964, P = 0.034), shorter LOS. Also, TAVR patients had lower rates of cardiac and respiratory complications, PPM, AKI, and discharge to an outside facility compared with the SAVR group.

Conclusion

In patients with severe aortic stenosis and concomitant mitral stenosis, TAVR is a safe and attractive option for patients undergoing AVR with less complications compared with SAVR.

     

Bioprosthetic aortic valve leaflet disruption with high energy electrocautery to prevent coronary artery obstruction during valve‐in‐valve transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is well‐established for the treatment of bioprosthetic aortic valve stenosis (AS) in high surgical risk patients. Coronary artery obstruction from displacement of the bioprosthetic valve leaflets during valve‐in‐valve (VIV) TAVR is a rare, but potentially fatal, complication. Recently, the bioprosthetic aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) procedure was developed as a method for disrupting bioprosthetic leaflets in patients undergoing VIV TAVR at high risk for coronary obstruction. This case describes a successful VIV TAVR utilizing a simplified concept of the BASILICA technique in a patient where the full procedure could not be completed.     

Retrograde percutaneous aortic valve implantation for critical aortic stenosis.

Recently, a prosthetic aortic valve has been implanted percutaneously in several patients using an antegrade transseptal approach. This has been shown to be feasible and associated with dramatic hemodynamic improvement. We report a retrograde implantation of a percutaneous heart valve (PHV) in an 84-year-old man with critical aortic stenosis and refractory congestive heart failure after difficulties encountered with an initial antegrade approach. While attempting antegrade transseptal implantation of a PHV, the anterior leaflet of the mitral valve was tethered by the guidewire resulting in severe mitral regurgitation and pulseless electrical activity. Cardiac resuscitation was successful. Utilizing a retrograde approach, the PHV was successfully implanted in a stable position below the coronary ostia and well above the mitral valve leaflets. The aortic valve area increased from 0.55 to 1.7 cm2 with only mild paravalvular aortic regurgitation. Despite marked improvement in aortic valve function, the patient died secondary to guidewire-induced mitral valve anterior leaflet laceration, severe mitral regurgitation, and cardiogenic shock. Retrograde implantation of a PHV can be successfully performed with substantial increase in aortic valve area and an acceptable degree of aortic regurgitation. Although the retrograde approach may be associated with greater risk of vascular access site complications, it may be considerably safer by avoiding potential guidewire injury to the mitral valve. Further refinements in technique may establish the retrograde approach as the preferred means of PHV implantation in nonsurgical patients with critical aortic stenosis.     

Iatrogenic left main coronary artery stenosis after aortic and mitral valve replacement

A case of 48-year old patient, who developed anginal symptoms 3 months after aortic and mitral valves replacement was presented. The patient underwent coronary angiography, which revealed severe left main coronary stenosis. Successful surgery was done with grafting of left anterior descending and circumflex arteries. Opinions on etiology, diagnosis and management of this rare complication are discussed.     

Carotid artery access for transcatheter aortic valve replacement

We report three patients who had successful transcatheter aortic valve replacement (TAVR) via carotid artery access. None were candidates for thoracotomy (including minimal access incisions) and had no other vascular access sites that would accommodate the transcatheter valve sheath. Antegrade carotid perfusion and retrograde insertion of the delivery sheath maintained cerebral blood flow without sequelae. Carotid access for TAVR is an option for unusual patients without other access. © 2012 Wiley Periodicals, Inc.     

Off-pump bypass grafting in patients with significant left main coronary artery stenosis

The aim of this study was to investigate and determine whether patients with significant (%50) left main coronary artery stenosis could undergo coronary bypass on the beating heart and compare the results to those obtained using the conventional method. Prospectively collected data of patients with significant left main coronary artery disease who had undergone coronary bypass on the beating heart (group A, n = 100) or with the conventional method (group B, n = 100) were evaluated retrospectively. EuroSCORE values, preoperative and operative details, postoperative morbidity and mortality, and early results were compared. Groups were similar in terms of EuroSCORE, demographics, and preoperative variables. Number of distal anastomoses per patient was 3.1 ± 0.9 in the beating heart group while it was 3.3 ± 0.9 in the conventional group (P = 0.09). Patients operated on with the conventional method had higher levels of peak creatine kinase-myocardial band, blood and blood product transfusions, and inotropic requirements, while mechanical ventilation times and hospital stay were longer. The incidence of postoperative atrial fibrillation, mediastinitis, and intra-aortic balloon usage were comparable between the groups. There was no neurological complication in group A whereas five major neurological complications (three transient ischemic attacks, two strokes) occurred in group B (P = 0.06). Thirty-day mortality occurred in one patient in the beating heart group whereas five early deaths were observed in the conventional group (P = 0.21). In significant left main coronary artery stenosis coronary bypass on the beating heart is a safe and effective alternative to the conventional method with the same or better early results. The long-term results need to be evaluated.     

左主干急性闭塞或狭窄所致急性心肌梗死的急诊介入治疗

目的总结左主干急性闭塞或狭窄所致急性心肌梗死(AMI)患者急诊经皮冠状动脉介入治疗(PCI)的经验,探讨急诊PCI在此类患者中的安全性和有效性。方法从1995年1月至2004年12月,在1343例急诊PCI中,共有11例梗死相关血管为左主干。11例患者均为男性,年龄43~70岁,平均(56·4±9·2)岁,其中6例(54·5%)入院时即存在严重心原性休克。所有患者均在主动脉内球囊反搏支持下接受急诊PCI治疗。结果8例急诊置入支架,余3例仅行球囊扩张,后者有2例术后接受急诊冠状动脉旁路移植术。住院期间死亡5例(45·5%),存活的6例患者均完成3个月随访,其中4例随访超过2年,1例于术后4年猝死,1例患者术后5年重复造影检查结果良好。对比分析提示术前存在良好的侧支循环可能是影响此类患者急诊PCI术后疗效的因素。结论左主干急性闭塞或严重狭窄所致的AMI患者病情凶险,急性期死亡率高。侧支循环形成与否,治疗策略和预后不同,主动脉内球囊反搏支持下急诊PCI治疗可以挽救部分患者的生命和改善预后,对于侧支循环不良的患者,部分再灌注策略可能为一种有效手段之一,值得进一步研究。     

Utility of the guideliner catheter for percutaneous coronary interventions in patients with prior transcatheter aortic valve replacement

The safety and utility of GuideLiner catheters in complex percutaneous coronary interventions (PCI) has been well established. Patients with prior trans‐catheter aortic valve replacement especially with CoreValve, who present for PCI, pose a unique set of challenges. Not only does the operator often encounter difficulty with selective engagement of coronary ostia through the struts of the CoreValve, but also the complex nature of the underlying CAD in this high‐risk population. We present a case series to illustrate the use of GuideLiner catheter as an adjunctive tool for PCI in this patient population.     

Influence of coronary artery disease and percutaneous coronary intervention on mid‐term outcomes in patients with aortic valve stenosis treated with transcatheter aortic valve implantation

BackgroundA high frequency of coronary artery disease (CAD) is reported in patients with severe aortic valve stenosis (AS) who undergo transcatheter aortic valve implantation (TAVI). However, the optimal management of CAD in these patients remains unknown.HypothesisWe hypothesis that AS patients with TAVI complicated by CAD have poor prognosis. His study evaluates the prognoses of patients with CAD and severe AS after TAVI.MethodsWe divided 186 patients with severe AS undergoing TAVI into three groups: those with CAD involving the left main coronary (LM) or proximal left anterior descending artery (LAD) lesion (the CAD[LADp] group), those with CAD not involving the LM or a LAD proximal lesion (the CAD[non‐LADp] group), and those without CAD (Non‐CAD group). Clinical outcomes were compared among the three groups.ResultsThe CAD[LADp] group showed a higher incidence of major adverse cardiovascular and cerebrovascular events (MACCEs) and all‐cause mortality than the other two groups (log‐rank p = .001 and p = .008, respectively). Even after adjustment for STS score and percutaneous coronary intervention (PCI) before TAVI, CAD[LADp] remained associated with MACCE and all‐cause mortality. However, PCI for an LM or LAD proximal lesion pre‐TAVI did not reduce the risk of these outcomes.ConclusionsCAD with an LM or LAD proximal lesion is a strong independent predictor of mid‐term MACCEs and all‐cause mortality in patients with severe AS treated with TAVI. PCI before TAVI did not influence the outcomes.     

Transcatheter versus surgical aortic valve replacement in severe, symptomatic aortic stenosis

Aortic stenosis (AS) is the most common type of valvular heart disease in the elderly. Surgical aortic valve replacement (SAVR) has been the standard practice for treating severe, symptomatic AS, but recently new treatment options have emerged. Transcatheter aortic valve replacement (TAVR) is now an established treatment option in patients at high surgical risk. In this review, we focus on recent developments and compare the two treatment methods in specific populations in terms of efficacy and safety (e.g., in patients with history of prior thoracic surgery, type of anesthesia employed, access site used or need for permanent pacing). The impact of comorbidities (pulmonary hypertension, arterial hypertension and obesity paradox), the cost-effectiveness of TAVR vs. SAVR and advances in transcatheter valve technology as well as issues that merit further investigation are further discussed. Moreover, outcomes and complications of TAVR in patients of different risk category (extremely high, high, intermediate and low risk) are analyzed. We strongly believe that during the following years, TAVR may evolve as the treatment of choice in a broader group of patients with symptomatic AS and beyond those with intermediate and high-risk features.     

Fatal ischemic stroke related to nonpermissive peripheral artery access for percutaneous aortic valve replacement.

This report describes an 85 year-old man who underwent percutaneous aortic valve replacement (PAVR). With a logistic euroSCORE of 37%, the patient had been refused surgical aortic valve replacement because of an unacceptably high peri-operative risk. During the PAVR procedure, severe resistance was encountered when advancing the 21 Fr delivery catheter through the left iliac artery despite pre-dilatation with a 7 mm balloon. Following this, PAVR was promptly achieved without difficulty, with excellent valve positioning, no peri-valvular leak and good hemodynamics. However, transesophageal echocardiography revealed a mobile echogenic mass within the outflow tract of the left ventricle. The mass was retrieved with a cardiac bioptome manipulated via the left femoral artery through a 9 Fr sheath. A right cerebral ischemic stroke manifested shortly after the post-procedure and the patient died on the fourth post-operative day. Post-mortem findings revealed a left subclavian artery occlusion by iliac vascular tissue. This report highlights the imperative for device-specific vascular access screening criteria and the need to minimize device size in order to safely accomplish PAVR.