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Non-ST-elevation myocardial infarction after complex percutaneous coronary intervention and transcatheter aortic valve implantation: a case report of bioprosthesis-related delayed coronary obstruction and its difficult diagnosis.

ABSTRACT: Background:There is a high coincidence of significant coronary artery disease and severe aortic stenosis. Coronary revascularization should be performed prior to transcatheter aortic valve implantation (TAVI). We report a case of non-ST-elevation myocardial infarction (NSTEMI) after complex percutaneous coronary intervention (PCI) prior to TAVI, where differential diagnosis between coronary stent failure and bioprosthesis-related sinus obstruction was substantial. Case summary:A 79-year-old woman was re-admitted to the hospital 5?days after TAVI due to troponin-negative new-onset angina. She underwent complex PCI 3?days before TAVI and was not compliant to medications. Symptoms initially resolved after re-establishment of anti-hypertensive treatment. There were no signs of aortic bioprosthesis failure, paravalvular leak, or myocardial ischaemia. After 1 month, the symptoms re-occurred. Due to elevated troponins, myocardial ischaemia in electrocardiogram and new contractility disorders, NSTEMI was diagnosed. Because it was impossible to intubate the left coronary artery (LCA), cardiac surgery was performed. Calcified native coronary leaflet was pushed by the stent frame of aortic bioprosthesis towards LCA ostium causing its subtotal occlusion. Transcatheter heart valve (THV) was removed and the new surgical aortic bioprosthesis was implanted. Further hospitalization and 1-month follow-up were uneventful. Discussion:Pre-procedural assessment is crucial prior to THV interventions. Delayed coronary obstruction caused by the native leaflet is extremely rare and potentially fatal complication of TAVI. The diagnosis is difficult and high clinical suspicion is required to detect this pathology. Given our experience, the indication towards interventional or surgical repair should be established faster to avoid coronary ischaemia.

SUBMITTER: Rudzinski PN

PROVIDER: S-EPMC7649483 | biostudies-literature | 2020 Oct

REPOSITORIES: biostudies-literature

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Non-ST-elevation myocardial infarction after complex percutaneous coronary intervention and transcatheter aortic valve implantation: a case report of bioprosthesis-related delayed coronary obstruction and its difficult diagnosis.

Rudziński Piotr Nikodem PN Mach Markus M Gross Christoph C Andreas Martin M

European heart journal. Case reports 20200909 5

<h4>Background</h4>There is a high coincidence of significant coronary artery disease and severe aortic stenosis. Coronary revascularization should be performed prior to transcatheter aortic valve implantation (TAVI). We report a case of non-ST-elevation myocardial infarction (NSTEMI) after complex percutaneous coronary intervention (PCI) prior to TAVI, where differential diagnosis between coronary stent failure and bioprosthesis-related sinus obstruction was substantial.<h4>Case summary</h4>A 7 ...[more]

PMID: 33204974

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Project description:Background Despite restoration of epicardial flow following primary percutaneous coronary intervention (PPCI), microvascular reperfusion as reflected by ST-elevation resolution (ST-ER) resolution remains variable and its pathophysiology remains unclear. Methods and Results Using principal component analyses, we explored associations between 91 serum biomarkers drawn before PPCI clustered into 14 pathobiologic processes (including NT-proBNP [N-terminal pro-B-type natriuretic peptide] as an independent cluster), and (1) ST-ER resolution ≥50% versus <50%; and (2) 90-day composite of death, shock, and heart failure. Network analyses were performed to understand interbiomarker relationships between the ST-ER groups. Among the 1160 patients studied, 861 (74%) had ST-ER ≥50% at a median 40 (interquartile range, 23-70) minutes following PPCI, yet both groups had comparable post-PPCI TIMI (Thrombolysis in Myocardial Infarction) grade 3 flow (86.6% versus 82.9%; P=0.25). ST-ER ≥50% was associated with significantly lower pre-PPCI concentrations of platelet activation cluster (particularly P-selectin, von Willebrand factor, and platelet-derived growth factor A) and NT-proBNP, including after risk adjustment. Across both ST-ER groups, strong interbiomarker relationships were noted between pathways indicative of myocardial stretch, platelet activation, and inflammation, whereas with ST-ER <50% correlations between iron homeostasis and inflammation were observed. Of all 14 biomarker clusters, only NT-proBNP was significantly associated with the 90-day clinical composite. Conclusions Suboptimal ST-ER is common despite achieving post-PPCI TIMI grade 3 flow. The cluster of platelet activation proteins and NT-proBNP were strongly correlated with suboptimal ST-ER and NT-proBNP was independently associated with 90-day outcomes. This analysis provides insights into the pathophysiology of microvascular reperfusion in ST-segment-elevation myocardial infarction and suggests novel pre-PPCI risk targets potentially amenable to enhancing tissue-level reperfusion following PPCI.

Dataset Information

Non-ST-elevation myocardial infarction after complex percutaneous coronary intervention and transcatheter aortic valve implantation: a case report of bioprosthesis-related delayed coronary obstruction and its difficult diagnosis.

Publications

Non-ST-elevation myocardial infarction after complex percutaneous coronary intervention and transcatheter aortic valve implantation: a case report of bioprosthesis-related delayed coronary obstruction and its difficult diagnosis.

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