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.     

A unique cause of coronary obstruction after transcatheter aortic valve replacement

Delayed coronary obstruction is a rare but often fatal complication of transcatheter aortic valve replacement that can present within 24 hr after the transcatheter aortic valve replacement procedure. We present a case of a 77-year-old woman whose distal left main coronary artery bifurcation became obstructed by an embolized piece of native valve leaflet material 16 hours after the uncomplicated transfemoral implantation of an Edwards Sapien Ultra 23 mm aortic valve, which was successfully treated with the simultaneous kissing stent technique.     

Transcatheter Aortic Valve Implantation Despite Challenging Vascular Access

We describe transcatheter aortic valve implantation in a patient who had severe peripheral artery disease. The patient''s vascular condition required additional preliminary peripheral intervention to enable adequate vascular access.A 78-year-old man with severe aortic stenosis, substantial comorbidities, and severe heart failure symptoms was referred for aortic valve replacement. The patient''s 20-mm aortic annulus necessitated the use of a 23-mm Edwards Sapien valve inserted through a 22F sheath, which itself needed a vessel diameter of at least 7 mm for percutaneous delivery. The left common femoral artery was selected for valve delivery. The left iliac artery and infrarenal aorta underwent extensive intervention to achieve an intraluminal diameter larger than 7 mm. After aortic valvuloplasty, valve deployment was successful, and the transaortic gradient decreased from 40 mmHg to less than 5 mmHg. The patient was discharged from the hospital 4 days postoperatively. We conclude that transcatheter aortic valve implantation can be successfully performed in patients with obstructed vascular access, including stenosis of the infrarenal aorta and the subclavian and coronary arteries.     

Should a Regurgitant Mitral Valve Be Replaced Simultaneously with a Stenotic Aortic Valve?

Mitral valve regurgitation frequently accompanies aortic valve stenosis. It has been suggested that mitral regurgitation improves after aortic valve replacement alone and that the mitral valve need not be replaced simultaneously Furthermore, mitral regurgitation associated with coronary artery disease, particularly in patients with poor left ventricular function, shows immediate improvement after coronary artery bypass grafting. We studied 60 consecutive patients with aortic stenosis and mitral regurgitation to determine the degree of improvement in mitral regurgitation after aortic valve replacement alone versus aortic valve replacement combined with coronary artery bypass grafting. Thirty-six of the patients had normal coronary arteries (Group 1); the other 24 had symptomatic coronary artery disease requiring bypass surgery (Group 2). Echocardiography was performed preoperatively, 1 week postoperatively, and at follow-up. In Group 1, left ventricular ejection fraction did not improve early or at 2.5 months postoperatively, but mitral regurgitation improved gradually during follow-up. In Group 2, mitral regurgitation showed improvement 1 week postoperatively (p < 0.001), and left ventricular ejection fraction was improved at 2.5 months. We conclude that patients with aortic valve stenosis and mild-to-severe mitral regurgitation, without echocardiographic signs of chordal or papillary muscle rupture and without coronary artery disease, should undergo aortic valve replacement alone. The mitral regurgitation will remain the same or improve. For patients with coexisting coronary artery disease, simultaneous aortic valve replacement and coronary artery bypass grafting are imperative; however, the mitral valve again requires no intervention, since mitral regurgitation improves significantly after the other 2 procedures.     

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.     

Incidental Left Atrial Blood Cyst in a Patient Undergoing Transcatheter Aortic Valve Replacement

Blood cysts of the heart are benign cardiovascular tumors found incidentally in approximately 50% of infants who undergo autopsy at less than 2 months of age. These congenital cysts, frequently present on the atrioventricular valves of infants, are exceedingly rare in adults. Nonetheless, in adults, cardiac blood cysts have been found on the mitral valve, papillary muscles, right atrium, right ventricle, left ventricle, and aortic, pulmonic, and tricuspid valves. Reported complications include left ventricular outflow obstruction, occlusion of the coronary arteries, valvular stenosis or regurgitation, and embolic stroke.In high-risk patients with severe aortic stenosis, transcatheter aortic valve replacement has emerged as an alternative to surgical replacement. Transesophageal echocardiography plays a fundamental role in evaluating the feasibility of intraprocedural transcatheter aortic valve replacement, in measuring aortic annular size, in guiding placement of the prosthetic device, and in looking for possible complications. The embolic risk of rapid pacing and transcatheter aortic valve replacement in a patient with an intracardiac blood cyst is unknown, and such a case has not, to our knowledge, been reported heretofore. We present the case of a 78-year-old woman with severe aortic stenosis, in whom a blood cyst was incidentally found in the left atrium upon transesophageal echocardiography. She underwent successful transcatheter aortic valve replacement without embolic complication.     

Coronary Ostial Stenosis after Aortic Valve Replacement: Successful Treatment of 2 Patients with Drug-Eluting Stents

Coronary ostial stenosis is a rare but potentially serious sequela after aortic valve replacement. It occurs in the left main or right coronary artery after 1% to 5% of aortic valve replacement procedures. The clinical symptoms are usually severe and may appear from 1 to 6 months postoperatively. Although the typical treatment is coronary artery bypass grafting, patients have been successfully treated by means of percutaneous coronary intervention.Herein, we present the cases of 2 patients in whom coronary ostial stenosis developed after aortic valve replacement. In the 1st case, a 72-year-old man underwent aortic valve replacement and bypass grafting of the saphenous vein to the left anterior descending coronary artery. Six months later, he experienced a non-ST-segment-elevation myocardial infarction. Coronary angiography revealed a critical stenosis of the right coronary artery ostium. In the 2nd case, a 78-year-old woman underwent aortic valve replacement and grafting of the saphenous vein to an occluded right coronary artery. Four months later, she experienced unstable angina. Coronary angiography showed a critical left main coronary artery ostial stenosis and occlusion of the right coronary artery venous graft. In each patient, we performed percutaneous coronary intervention and deployed a drug-eluting stent. Both patients were asymptomatic on 6-to 12-month follow-up. We attribute the coronary ostial stenosis to the selective ostial administration of cardioplegic solution during surgery. We conclude that retrograde administration of cardioplegic solution through the coronary sinus may reduce the incidence of postoperative coronary ostial stenosis, and that stenting may be an efficient treatment option.Key words: Angioplasty, transluminal, percutaneous coronary; aortic valve/surgery; cardiac surgical procedures/adverse effects; coronary artery disease/etiology/prevention & control; coronary stenosis/diagnosis/etiology/therapy; heart valve prosthesis implantation/adverse effects; iatrogenic disease/prevention & control; perfusion/adverse effects/instrumentation; postoperative complications/therapy; treatment outcomeCoronary ostial stenosis is a rare but potentially serious postoperative sequela of aortic valve replacement (AVR). Ostial stenosis can occur in the left main coronary artery (LMCA) or in the right coronary artery (RCA). The condition, first described by Roberts and Morrow in 1967,¹ is believed to occur after 1% to 5% of AVR procedures.^2–7 No underlying cause has been determined. The clinical symptoms of coronary ostial stenosis are usually severe and can appear from 1 to 6 months postoperatively.^8,9 Although the typical treatment is coronary artery bypass grafting (CABG), patients have been successfully treated by means of percutaneous coronary intervention (PCI).^10–15 Herein, we present the cases of 2 patients in whom coronary ostial stenosis developed after AVR, discuss their PCI treatment, and offer our conclusion regarding the feasibility of PCI in the treatment of coronary ostial stenosis.     

Iatrogenic left main coronary artery stenosis following PTCA or valve replacement

We report three patients who developed iatrogenic severe left main coronary artery stenosis. In two, it was secondary to coronary cannulation during aortic valve replacement and in one it followed distention of the artery during balloon dilatation of a proximal lesion in the left anterior descending artery. In all three, the stenosis was clinically manifest a few months after the intervention. All were successfully treated by aortosaphenous coronary bypass. A common mechanism for the three cases may be mechanical distention of the left main coronary artery resulting in intimal damage with secondary fibrosis and stenosis. The percutaneous transluminal coronary angioplasty-related stenosis is, to our knowledge, the first reported case of this nature, and represents a previously unrecognized complication of this procedure.     

Coronary artery disease and TAVI: Current evidence on a recurrent issue

Coronary artery disease (CAD) is a frequent finding in patients with aortic stenosis (AS). Concomitant coronary artery bypass and aortic valve replacement is considered the gold standard treatment in surgical candidates. However, limited evidence is available regarding the role of coronary revascularization in patients undergoing transcatheter aortic valve implantation (TAVI). How to evaluate CAD severity in patients with AS, whether percutaneous coronary intervention (PCI) needs to be performed and what is the timing for revascularization to minimize procedural risks, remains matters of debate. The aim of this review is to summarize epidemiology, diagnostic tools and possible options for CAD management in patients undergoing TAVI with specific focus on the pros and the cons of the different timing of PCI.     

Iatrogenic ostial stenosis of the left coronary artery. Report of a case with Starr-Edwards aortic prosthesis (author's transl)

A case of a 41 years-old-man, who had undergone surgical intervention ten years previously for aortic valve replacement in ECC with the coronary perfusion technique, is reported. This patient was studied because of the appearance of angina pectoris three months after the intervention and its progressive development. Selective left coronary angiography showed an ostial subocclusive stenosis; the run-off from the right coronary artery provided distal blood supply to the left coronary artery. A venous bypass was implanted between the aorta and the left anterior descending branch; the prosthesis was substituted because it was altered and caused hemolysis' problems. In accordance with most Authors late ostial coronary stenosis is a complication of the coronary perfusion technique, which is adopted for myocardial protection during surgical interventions for aortic valve replacement.     

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.     

The use of MitraClip to prevent posttranscatheter aortic valve replacement left ventricular “suicide”

Patients with concomitant severe aortic stenosis (AS) and left ventricular outflow tract (LVOT) obstruction undergoing transcatheter aortic valve replacement (TAVR) are at risk for hemodynamic collapse due to a sudden decrease in afterload causing worsening LVOT obstruction. We present a case of an 88-year-old female with symptomatic, severe AS, and LVOT obstruction with systolic anterior motion (SAM) of the mitral leaflet in whom alcohol septal ablation was contraindicated secondary to a chronic total occlusion of the right coronary artery that filled retrograde via septal collaterals. MitraClip at the time of TAVR was successfully performed to treat SAM with subsequent stabilization of LVOT gradients despite treatment of the patient's AS. This novel approach may represent a feasible option to prevent hemodynamic complications after TAVR in patients with significant LVOT obstruction secondary to SAM and AS.     

Bail out lithotripsy to treat delayed valve-in-valve TAVR-related coronary obstruction

Coronary access difficulty and stent compression by the juxtaposed aortic valve leaflet hamper percutaneous management of delayed coronary artery obstruction (CAO) after valve-in-valve (Edwards Sapien 3 in St. Jude Trifecta) transcatheter aortic valve replacement (TAVR). Here, we present a case of delayed post-TAVR CAO treated with intravascular lithotripsy and multistenting to overcome stent compression by the adjacent calcified leaflet.     

Aortic valve cusp shearing and migration into the left main coronary artery during transcatheter aortic valve implantation

In inoperable or high-risk patients with severe aortic stenosis, transcatheter aortic valve implantation (TAVI) provides an efficacious and safe alternative to surgical aortic valve replacement. In this case report, TAVI resulted in aortic valve cusp shearing and migration into the left main coronary artery, resulting in occlusion of coronary blood flow and cardiac arrest. The patient underwent immediate cardiopulmonary support and surgical intervention with a favourable outcome. With this case report, we illustrate the etiology and management of this complication, which can be recognized nonsurgically only if a high index of suspicion exists.     

When is concomitant aortic valve replacement indicated in patients with mild to moderate stenosis undergoing coronary revascularization?

Mild to moderate aortic stenosis is a common finding in patients presenting for coronary artery bypass grafting (CABG), and its management is controversial. However, review of available data suggests a surgical strategy for these patients. Recent data demonstrate that 1) progression of aortic stenosis is more rapid in those with leaflet calcification; 2) the addition of aortic valve replacement to CABG in patients with mild to moderate stenosis does not increase hospital mortality when compared with bypass surgery alone; 3) hospital mortality for aortic valve replacement after previous bypass surgery has declined in recent years; 4) aortic valve replacement places the patient at risk for prosthesisrelated complications; 5) the limited 10-year survival (competing risk of death) leaves only a minority of individuals with mild aortic stenosis alive and eligible for aortic valve replacement 10 years after bypass surgery; and 6) combined aortic valve replacement and CABG confers a survival benefit in those with moderate aortic stenosis but not in those with mild aortic stenosis. Therefore, in the coronary artery bypass patient with moderate aortic stenosis, leaflet calcification, and life expectancy greater than 5 years, concomitant aortic valve replacement is advised. In contrast, aortic valve replacement is rarely indicated in those with mild aortic stenosis.     

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.     

Aortic valve replacement in patients with mild or moderate aortic stenosis and coronary bypass surgery

PURPOSE: To assess whether there is survival benefit for patients with mild or moderate aortic stenosis if they undergo aortic valve replacement at the time of coronary artery bypass surgery. METHODS: From 1985 to 1995 we evaluated all patients at our institution who underwent coronary artery bypass surgery and who had the echocardiographic diagnosis of mild (mean gradient <0 mm Hg and/or valve area >1.5 cm(2)) or moderate (mean gradient > or =30 and < or =40 mm Hg and/or valve area >1.0 < or =1.5 cm(2)) aortic stenosis. Using propensity analysis, survival was compared between 129 patients who underwent coronary artery bypass surgery alone and 78 patients who underwent concomitant coronary artery bypass surgery and aortic valve replacement. RESULTS: Perioperative mortality was similar among patients who underwent coronary artery bypass surgery alone compared with patients who underwent concomitant coronary artery bypass surgery and aortic valve replacement. By Kaplan-Meier analysis, 1-year and 8-year survival were better at 90% and 55% for patients who underwent concomitant coronary artery bypass surgery and aortic valve replacement compared with 85% and 39% for patients who underwent coronary artery bypass surgery alone (P <0.001). This benefit was limited to patients with moderate aortic stenosis (propensity-adjusted relative risk = 0.43; 95% confidence interval: 0.20 to 0.96; P = 0.04). CONCLUSION: Concomitant aortic valve replacement at the time of coronary artery bypass surgery for mild or moderate aortic stenosis appears to convey a survival advantage for patients with moderate aortic stenosis but not for those with mild aortic stenosis.     

Surgical implications and results of combined aortic valve replacement and myocardial revascularization.

To better define the indications for and results of simultaneous aortic valve replacement and myocardial revascularization, a cohort of 271 patients with angiographically defined coronary anatomy who underwent xenograft bioprosthetic aortic valve replacement were analyzed. Two hundred and twelve patients had predominant aortic stenosis, and 55 had pure aortic regurgitation. Discordance between the clinical assessment of angina and the angiographic assessment of coronary artery disease was apparent in 39 percent of the patients with aortic stenosis and 45 percent of the patients with aortic regurgitation. Thirty-seven percent of patients in the aortic stenosis subgroup without angina and 41 percent of patients in the aortic regurgitation subgroup without angina had hemodynamically significant coronary artery disease. Concomitant coronary artery bypass grafting and aortic valve replacement were performed in 101 patients. The incidence of perioperative myocardial infarction and operative death was significantly greater (P < 0.05) in the subsets of patients with coronary disease than in those without coronary disease (9.9 percent versus 0.7 percent and 8.3 percent versus 2.2 percent, respectively). Late postoperative angina and myocardial infarction also correlated with the preoperative presence of coronary artery disease. Excluding operative mortality, the late actuarial survival rate (mean follow-up, 1.6 years; maximal follow-up, 4.9 years) was not statistically lower for the patients with coronary disease.It is concluded that angina pectoris in patients with aortic valve disease is not a reliable indicator of coronary artery disease and that patients with coronary disease who undergo aortic valve replacement have an increased risk. It is inferred from this study that preoperative coronary arteriography is advisable in most adults undergoing the evaluation of aortic valve disease and that simultaneous aortic valve replacement and myocardial revascularization may provide some protection against late attrition due to the combined effects of coexistent aortic valve and coronary artery disease.     

Apico-Aortic Conduit for severe aortic stenosis: Technique,applications, and systematic review

Patients referred for aortic valve replacement are often elderly and may have increased surgical risk associated with ascending aortic calcification, left ventricular dysfunction, presence of coronary artery disease, previous surgery, and/or presence of several co-morbidities. Some of these patients may not be considered candidates for conventional surgery because of their high risk profile. While transcatheter aortic valve replacement constitutes a widely accepted alternative, some patients may not be eligible for this modality due to anatomic factors. Apico-Aortic Conduit (AAC) insertion (aortic valve bypass surgery) constitutes a possible option in those patients. Apico-Aortic Conduit is not a new technique, as it has been used for decades in both pediatric and adult populations. However, there is a resurging interest in this technique due to the expanding scope of elderly patients being considered for the treatment of aortic stenosis. Herein, we describe our surgical technique and provide a systematic review of recent publications on AAC insertion, reporting that there is continued use and several modifications of this technique, such as performing it through a small thoracotomy without the use of the cardiopulmonary bypass.Abbreviations: AAC, Apico Aortic Conduit; AS, aortic stenosis; AVR, aortic valve replacement; BSA, body surface area; CABG, coronary artery bypass grafting surgery; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; CPB, cardiopulmonary bypass; DHCA, deep hypothermic circulatory arrest; FEM-FEM, femoro-femoral; ITA, internal thoracic artery; LITA, left internal thoracic artery; LVH, left ventricular hypertrophy; LVOT, left ventricle outflow tract; NYHA, New York Heart Association; MDCT, multidetector-computerized tomography; MVR, mitral valve replacement; OPCAB, off pump coronary artery bypass; PH, pulmonary hypertension; RITA, right internal thoracic artery; TEE, transesophageal echocardiography; TAVI, transcatheter aortic valve implantation     

A case of anomalous left coronary artery obstruction caused by lotus valve implantation

Trans‐catheter aortic valve implantation (TAVI) in patients with high surgical risk is an alternative therapeutic option for severe aortic stenosis. Although second generation TAVI devices are available now, this therapy still cannot overcome all serious complications. Among them, coronary obstruction is a life threatening complication, however, there is no report concerning the complication in patients with anomalous coronary arteries. Here we present a case with coronary obstruction of an anomalous left main coronary that occurred after implantation of the mechanical expanding Lotus valve (Boston Scientific Inc.). © 2016 Wiley Periodicals, Inc.