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Rescue aortic balloon valvuloplasty during procedural cardiac arrest while treating critical left main stem stenosis: a case report.

ABSTRACT: Background:Best timing for coronary revascularization in patients with severe aortic stenosis (AS) who was a candidate for transcatheter aortic valve implantation (TAVI) is still matter of debate. Case summary:We here report the case of an 87-year-old man with severe AS presenting with non-ST-segment elevation myocardial infarction. Coronary angiography revealed a highly complex and calcific left main stem (LMS) lesion. Rotablation-assisted percutaneous coronary intervention (PCI) was attempted but was complicated by post-stenting rapidly evolving haemodynamic impairment. A rescue 'pacing-free' balloon aortic valvuloplasty (BAV) was performed to rescue the patients, allowing prompt restoration of cardiac output and coronary perfusion. Discussion:According to guidelines and preliminary evidence, decision should be performed case by case and based on the degree of severity and complexity of either AS or coronary disease. The strategy of treating coronary lesions first may limit the risk of potential ischaemic complications during TAVI. However, the downside of it is the risk of hemodynamic crash with potential catastrophic evolution in case of PCI complications in presence of severe AS. A 'bailout BAV' can be considered as a salvage-strategy in case of complex and complicated LMS-PCI in the context of severe AS and advanced status of haemodynamic impairment. This approach must be seen as very last resort, while appropriate pre-procedural planning is still highly recommended in order to prevent potentially fatal procedural complications in this fragile clinical setting.

SUBMITTER: Benenati S

PROVIDER: S-EPMC7180547 | biostudies-literature | 2020 Apr

REPOSITORIES: biostudies-literature

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Rescue aortic balloon valvuloplasty during procedural cardiac arrest while treating critical left main stem stenosis: a case report.

Benenati Stefano S Scarsini Roberto R De Maria Giovanni Luigi GL Banning Adrian P AP Banning Adrian P AP

European heart journal. Case reports 20200221 2

<h4>Background</h4>Best timing for coronary revascularization in patients with severe aortic stenosis (AS) who was a candidate for transcatheter aortic valve implantation (TAVI) is still matter of debate.<h4>Case summary</h4>We here report the case of an 87-year-old man with severe AS presenting with non-ST-segment elevation myocardial infarction. Coronary angiography revealed a highly complex and calcific left main stem (LMS) lesion. Rotablation-assisted percutaneous coronary intervention (PCI) ...[more]

PMID: 32352066

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Project description:BackgroundAortic valve stenosis is the most common type of congenital left ventricular (LV) outflow tract obstruction. Balloon aortic valvuloplasty (BAV) has become the first-line treatment pathway in many centers. Our aim was to assess the trajectory of LV remodeling following BAV in children and its relationship to residual aortic stenosis (AS) and insufficiency (AI).MethodsChildren <18 years of age who underwent BAV for isolated aortic stenosis from 2004 to 2012 were eligible for inclusion. Those with AI before BAV, other complex congenital heart lesions, or <2 accessible follow-up echocardiograms were excluded. Baseline and serial echocardiographic data pertaining to aortic valve and LV size and function were retrospectively collected through December 2017 or the first reintervention. Longitudinal data was assessed using per-patient time profiles with superimposed trend lines using locally estimated scatterplot smoothing. Associations with reintervention or death were also evaluated.ResultsAmong the 98 enrolled children, the median (interquartile range) age at BAV was 2.8 months (0.2-75). The median (interquartile range) follow-up was 6.8 years (1.9-9.0). Children with predominantly residual AI (n=11) demonstrated progressive increases in their LV end-diastolic dimension Z score within the first 3 years after the BAV, followed by a plateau (P<0.001). Their mean LV circumferential and longitudinal strain values remained within the normal range but lower than in the non-AI group (P<0.001 and P=0.001, respectively). Children with predominantly residual aortic stenosis (n=44) had no changes in LV dimensions but had a rapid early increase in mean LV circumferential and longitudinal strain. The cumulative proportion (95% CI) of reintervention at 5 years following BAV was 33.7% (23.6%-42.4%).ConclusionsOur study demonstrates that LV remodeling occurs mainly during the first 3 years in children with predominantly residual AI after BAV, with no subsequent significant functional changes over the medium term. These data improve our understanding of expected patient trajectories and thus may inform decisions on the timing of reintervention.

Project description:AimsThe aim of the study was to evaluate left ventricular (LV) remodeling and systolic function using two-dimensional speckle tracking echocardiographic (2D STE) imaging in children at a long-term (more than 36 months, 107.5±57.8 months) after balloon valvuloplasty for aortic stenosis (BAV).Methods and results40 patients (mean age 9,68 years, 75% male) after BAV and 62 control subjects matched to the age and heart rate were prospectively evaluated. The 2D STE assessment of LV longitudinal and circumferential strain and strain rate was performed. Left ventricular eccentric hypertrophy (LVEH) was diagnosed in 75% of patients in the study group. Left ventricular ejection fraction (LVEF) was normal in all patients. In study group, global longitudinal strain (GLS), global longitudinal strain rate (GLSr) were significantly lower compared with the controls: GLS (-19.7±2.22% vs. -22.3±1.5%, P< 0.001), GLSr (-0.89±0.15/s vs. -1.04 ±0.12/s, P < 0.001). Regional (basal, middle and apical segments) strain and strain rate were also lower compared with control group. Global circumferential strain (GCS), global circumferential strain rate (GCSr) as well as regional (basal, middle and apical segments) strain and strain rate were normal. Multivariable logistic regression analysis included: instantaneous peak systolic Doppler gradient across aortic valve (PGmax), grade of aortic regurgitation (AR), left ventricular mass index (LVMI), left ventricular relative wall thickness (LVRWT), left ventricular end-diastolic diameter (LVEDd), peak systolic mitral annular velocity of the septal and lateral corner (S'spt, S'lat), LVEF before BAV and time after BAV and showed that the only predictor of reduced GLS was LV eccentric hypertrophy [odds ratio 6.9; (95% CI: 1.37-12.5), P = 0.045].ConclusionPatients at long-term observation after BAV present the subclinical LV systolic impairment, which is associated with the presence of its remodeling. Longitudinal deformation is the most sensitive marker of LV systolic impairment in this group of patients.

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Rescue aortic balloon valvuloplasty during procedural cardiac arrest while treating critical left main stem stenosis: a case report.

Publications

Rescue aortic balloon valvuloplasty during procedural cardiac arrest while treating critical left main stem stenosis: a case report.

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