Coronary Obstruction Following Transcatheter Aortic Valve Implantation

Abstract

BackgroundTranscatheter aortic valve implantation (TAVI) was established as an important alternative for high-risk patients with severe aortic stenosis. However, there are few data in the literature regarding coronary obstruction, that although rare, is a potentially fatal complication. ObjectiveEvaluate this complication in Brazil.MethodsWe evaluated all patients presenting coronary obstruction from the Brazilian Registry of TAVI. Main baseline and procedural characteristics, management of the complication, and clinical outcomes were collected from all patients.ResultsFrom 418 consecutive TAVI procedures, coronary obstruction occurred in 3 cases (incidence of 0.72%). All patients were women, without prior coronary artery bypass grafting (CABG), and with mean age of 85 ± 3 years, logistic EuroSCORE of 15 ± 6% and STS-PROM score of 9 ± 4%. All of the cases were performed with balloon-expandable Sapien XT prosthesis. In one patient, with pre-procedural computed tomography data, coronary arteries presented a low height and a narrow sinus of Valsalva. All patients presented with clinically significant severe maintained hypotension, immediately after valve implantation, and even though coronary angioplasty with stent implantation was successfully performed in all cases, patients died during hospitalization, being two periprocedurally.ConclusionCoronary obstruction following TAVI is a rare but potentially fatal complication, being more frequent in women and with the balloon-expandable prosthesis. Anatomical factors might be related with its increased occurrence, highlighting the importance of a good pre-procedural evaluation of the patients in order to avoid this severe complication.

Patient-specific image-based computer simulation for theprediction of valve morphology and calcium displacement after TAVI with the Medtronic CoreValve and the Edwards SAPIEN valve

“…This is particularly the case for the inflow portion of the valve as this is the site where most of the complications occur, for example paravalvular regurgitation and bundle branch block and also the rare but dramatic event of coronary obstruction [7][8][9][10][11][12][13] . Most likely, the overestimation unveils limitations of the software.…”

“…With respect to the latter, one might cite as examples incomplete and/or non-circular frame expansion due to the presence of aortic root calcifications leading to paravalvular regurgitation, unexpected mobilisation of calcified leaflets leading to coronary obstruction, and dissection or rupture of the aortic root even in the presence of appropriate valve size selection [7][8][9][10][11][12][13] . Device-host interactions are clinically difficult to predict because of the large variations in the geometry and dimensions of the aortic root in addition to the variations in the amount and distribution of calcium between patients.…”

Guide wire-balloon technique to prevent occlusion of the left main coronary artery during transcatheter aortic valve implantation: Case report

“…Clinical presentation may include hemodynamic impairment, hypotension, ST-T alterations, and newly developed segmental wall motion abnormalities. The most comprehensive evaluation on this subject was the review published by Ribeiro et al, [6] who found that coronary obstruction takes place in females, in patients who have not undergone a bypass, and in cases where an expandable valve was used. They also determined that the LMCA is obstructed more frequently than other arteries.…”

“…In addition, LMCA and right coronary artery obstructions have been reported after transfemoral implantation involving the Edwards Sapien XT valve. [7][8][9] The mechanisms of coronary obstruction are the following: [6] native cuspis displacement and an obstructed coronary ostium, a short distance (<10 mm) between the low-set ostial LMCA and the aortic annulus, serious calcification of the leaflets, a stenotic aortic root, and a shallow sinus of Valsalva. Although a low-set LMCA is a risk factor, the distance between the LMCA and annulus is >10 mm in half of the cases [6] because other mechanisms can make up for this troubling issue.…”

Comparison of the Clinical Outcomes in High-Risk Patients with Severe Aortic Stenosis Undergoing Transfemoral Aortic Valve Implantation Using SAPIEN XT and LOTUS Valve

“…Although TAVI has proven to be a less invasive treatment for high-risk patients with AS, it may be associated with potentially severe complications. [11][12][13][14] A recent meta-analysis including 11,210 patients from 41 studies demonstrated that the need for PPM ranged from 1% to 51%, with a median of 28% using the CoreValve device and 6% with the Edwards SAPIEN device. 15 In the REPRISE I study, which included 11 patients treated with the 23-mm LOTUS device, the need for PPM implantation arose in 36% of cases (N=4/11).…”