Severe Aortic Regurgitation After Transradial Percutaneous Coronary Intervention

Abstract

A 60-year-old man presented to a community hospital with new-onset shortness of breath after a 2-hour episode of typical chest pain. The ECG showed anteroseptal and inferior wall Q-waves. Serum troponin T levels were negative. An echocardiogram revealed anterior wall hypokinesia with left ventricular ejection fraction of 40% and no signs of valvular disease. The patient was transferred to our center for coronary angiography. Arterial access was obtained from the right radial artery. The angiogram showed mild disease of the left coronary artery and a right coronary artery (RCA) arising from the left coronary sinus. The RCA was extremely difficult to cannulate; nonselective injections revealed a long and severe stenosis of the mid segment ( Figure 1 and Movie 1). After many unsuccessful attempts to cannulate the RCA with different guiding catheters, the operator decided to engage first the left coronary artery with an Amplatz 2 guiding catheter. A BMW Universal II guide wire was advanced into the left anterior descending artery (LAD) for better stability. This approach made it possible to gently pull the guiding catheter back and to position its tip at the RCA ostium. This maneuver permitted the operator to advance a Choice PT guide wire into the RCA (Figure 2 and Movie 2). However, because the system was extremely unstable, the Amplatz catheter was removed and replaced with a 6F Multipurpose guiding catheter. The RCA was engaged using the same approach as described previously for the Amplatz catheter. Balloon predilatation was then performed, and selective cannulation of the RCA was made possible after removal of the LAD guide wire, with the RCA balloon still inflated. Successful percutaneous coronary intervention (PCI) with stenting of the mid RCA was then carried out ( Figure 3 and Movie 3). Cardiac MRI was performed immediately after PCI to investigate the reason for anterior wall hypokinesis in the presence of a normal LAD. Prior nontransmural anterior wall myocardial infarction and mild aortic regurgitation were present. The following day, a new diastolic regurgitation murmur was noted, and a transthoracic echocardiogram showed a new severe aortic regurgitation (Figure 4 and Movie 4). To better characterize the nature of this newly diagnosed valvulopathy, a 3-dimensional transesophageal echocardiogram was performed. The aortic regurgitation was the result of a tear and perforation of the left aortic leaflet ( Figure 5 and Movies 5 and 6). Consequently, the patient underwent aortic valve replacement. The anatomopathological examination confirmed the traumatic laceration of the left aortic leaflet (Figure 6). Figure 7 nicely depicts how the tip of the multipurpose guiding catheter was pressing on the aortic cusp during the procedure. This suggests that catheterinduced direct traumatic damage was the most probable mechanism of aortic regurgitation in this patient.Traumatic aortic valve laceration is a rare complication after cardiac catheterization. In the literature, there are 2 cases of aortic regurgitation a...

Severe chronic aortic regurgitation after percutaneous coronary intervention: a case report and literature review

“…Reports of secondary AR, e.g., due to aortic dissection, were excluded. Only 14 case reports involving 16 patients have been documented in the literature, 4–17 of which all but one describe the development of acute severe AR in contrast to our report ( Table 1 ). Most cases report catheter or guidewire as probable cause of laceration/perforation, while AR related to a protruding coronary stent was reported in only two cases.…”

“…Coronary angiography/PCI-induced severe AR is extremely rare, with a reported frequency of approximately 0.0001%, 4 and often associated with an acute presentation. We report an unusual presentation of PCI-induced severe AR, where the patient developed a chronic AR with associated progressive symptoms.…”

Aortic valve laceration following coronary angiography and percutaneous coronary intervention

“…Of the six previous reports of this complication in the literature between 1988 and 2016, three aortic valves were repaired and three were replaced . All cases were initially treated medically but ultimately required surgery.…”

“…Of the six previous reports of this complication in the literature between 1988 and 2016, three aortic valves were repaired 1-3 and | 687 three were replaced. [4][5][6] All cases were initially treated medically but ultimately required surgery. In all reported cases, surgical outcomes were excellent with no morbidity or mortality.…”

“…In two of the cases, injury was thought to be related to difficulty cannulating an anomalous right coronary artery. 5,6 In only one of these cases was there thought to be a preexisting factor, specifically a noncoronary cusp fenestration.…”