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Rotational atherectomy through a coronary artery bypass graft after transcatheter aortic valve implantation: a case report.

ABSTRACT: Background?:Aortic stenosis (AS) in the elderly is frequently associated with complex coronary artery disease. Rotational atherectomy (RA) in this clinical setting is challenging because coronary slow flow could lead to haemodynamic instability aggravated by the severe AS. Case summary?:We present the case of an 83-year-old woman with symptomatic severe AS, mildly decreased left ventricular ejection fraction and history of coronary artery bypass grafting with right internal mammary artery (RIMA) to the right coronary artery (RCA) and left internal mammary artery to the left anterior descending artery and further percutaneous coronary intervention (PCI) to the circumflex. First, we performed a transcatheter aortic valve implantation (TAVI) to treat the severe AS. Because of persistent symptoms despite good result, we then performed RA of the native RCA through the RIMA with a Guidezilla® guide extension catheter. Discussion?:A two-staged procedure of TAVI and PCI with RA of the RCA via RIMA was successfully performed. We decided to perform the PCI after the TAVI to allow a better haemodynamic tolerance of the complex coronary intervention. This procedure needs caution as the conduit is fragile and could be easily damaged during the RA. No data are available about feasibility and safety of RA through a native graft, but this could be a first step to consider it.

SUBMITTER: Illescas E

PROVIDER: S-EPMC7649512 | biostudies-literature | 2020 Oct

REPOSITORIES: biostudies-literature

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Rotational atherectomy through a coronary artery bypass graft after transcatheter aortic valve implantation: a case report.

Illescas Edgar E Cuisset Thomas T Spychaj Jean-Charles JC Deharo Pierre P

European heart journal. Case reports 20200923 5

<h4>Background</h4>Aortic stenosis (AS) in the elderly is frequently associated with complex coronary artery disease. Rotational atherectomy (RA) in this clinical setting is challenging because coronary slow flow could lead to haemodynamic instability aggravated by the severe AS.<h4>Case summary</h4>We present the case of an 83-year-old woman with symptomatic severe AS, mildly decreased left ventricular ejection fraction and history of coronary artery bypass grafting with right internal mammary ...[more]

PMID: 33204990

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Project description:Background As younger patients are being considered for transcatheter aortic valve implantation (TAVI), the assessment and treatment of concomitant coronary artery disease is taking on increased importance. Methods and Results Thirteen contemporary lower-risk patients with TAVI with severe aortic stenosis (AS) and moderate-severe coronary lesions were included. Patients underwent assessment of coronary hemodynamics in the presence of severe AS (pre-TAVI), in the absence of severe AS (immediately post-TAVI), and at longer-term follow-up (6 months post-TAVI). Fractional flow reserve decreased from 0.85 (0.76-0.88) pre-TAVI to 0.79 (0.74-0.83) post-TAVI, and then to 0.71 (0.65-0.77) at 6-month follow-up (P<0.001 for all comparisons). Conversely, instantaneous wave-free ratio was not significantly different: 0.82 (0.80-0.90) pre-TAVI, 0.83 (0.77-0.88) post-TAVI, and 0.83 (0.73-0.89) at 6 months (P=0.735). These changes are explained by the underlying coronary flow. Hyperemic whole-cycle coronary flow (fractional flow reserve flow) increased from 26.36 cm/s (23.82-31.82 cm/s) pre-TAVI to 30.78 cm/s (29.70-34.68 cm/s) post-TAVI (P=0.012), to 40.20 cm/s (32.14-50.00 cm/s) at 6-month follow-up (P<0.001 for both comparisons). Resting flow during the wave-free period of diastole was not significantly different: 25.48 cm/s (21.12-33.65 cm/s) pre-TAVI, 24.54 cm/s (20.74-27.88 cm/s) post-TAVI, and 25.89 cm/s (22.57-28.96 cm/s) at 6 months (P=0.500). Conclusions TAVI acutely improves whole-cycle hyperemic coronary flow, with ongoing sustained improvements at longer-term follow-up. This enhanced response to hyperemic stimuli appears to make fractional flow reserve assessment less suitable for patients with severe AS. Conversely, resting diastolic flow is not significantly influenced by the presence of severe AS. Resting indices of coronary stenosis severity, therefore, appear to be more appropriate for this patient population, although large-scale prospective randomized trials will be required to determine the role of coronary physiology in patients with severe AS.

Dataset Information

Rotational atherectomy through a coronary artery bypass graft after transcatheter aortic valve implantation: a case report.

Publications

Rotational atherectomy through a coronary artery bypass graft after transcatheter aortic valve implantation: a case report.

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