Delayed Coronary Obstruction After Transcatheter Aortic Valve Replacement.
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ABSTRACT:
SUBMITTER: Dhamija Y
PROVIDER: S-EPMC8288806 | biostudies-literature | 2019 Oct
REPOSITORIES: biostudies-literature
Publications
Delayed Coronary Obstruction After Transcatheter Aortic Valve Replacement.
Dhamija Yashu Y Kalra Ankur A Puri Rishi R
JACC. Case reports 20191016 3
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Project description:Coronary obstruction is an uncommon and severe complication after a transcatheter aortic valve replacement (TAVR), that occurs during the procedure in the vast majority of patients. In the present case even in the absence of classic risk factors, an acute coronary syndrome occurred one day after TAVR. Selective angiography revealed a severe left main ostium obstruction by the bulky native leaflet calcification. This is the first case of delayed presentation of coronary obstruction with a transfemoral balloon-expandable valve using the Inovare bioprosthesis (Braile Biomedica, Brazil). In addition, after drug-eluting stent placement in the left main coronary, intravascular ultrasound revealed severe stent underexpansion, so that a second layer of a bare-metal stent and high-pressure balloon post-dilatation was necessary to improve the final result. The patient was discharged after 7 days, and at the 6-month follow-up remained asymptomatic. <Learning objective: This case illustrates an unusual cause of an acute coronary syndrome 24 h after a transcatheter aortic valve replacement. This is the first report of this severe complication with delayed presentation following the balloon-expandable Inovare bioprosthesis. Even in the absence of classic risk factors this complication may occur, and percutaneous coronary intervention is feasible in the vast majority of cases, often requiring various percutaneous techniques and intravascular image to improve outcomes.>.
| S-EPMC8766319 | biostudies-literature
Project description:ObjectiveIn this study we aimed to evaluate risk of coronary obstruction during transcatheter aortic valve replacement and develop improved criteria based on computational modeling.MethodsPatient specific 3-dimensional models were constructed and validated for 28 patients out of 600 patients who were flagged as high risk for coronary obstruction (defined as meeting coronary ostium height < 14 mm and/or sinus of Valsalva diameter [SOVd] < 30 mm). The models consisted finite element analysis to predict the post- transcatheter aortic valve replacement native cusp apposition relative to the coronary ostium and were validated in vitro. The distance from cusp to coronary ostium (DLC) was derived from the 3-dimensional models and indexed with the coronary artery diameter to yield a fractional obstruction measure (DLC/d).ResultsTwenty-two out of 28 high-risk patients successfully underwent transcatheter aortic valve replacement without coronary obstruction and 6 did not. DLC/d between the 2 groups was significantly different (P < .00078), whereas neither coronary ostium height nor SOVd were significantly different (P > .32). A cutoff of DLC/d < 0.7 was predictive with 100% sensitivity and 95.7% specificity. The optimal sensitivity and specificity of coronary ostium height and SOVd in this high-risk group was only 60% and 40%, respectively, for cutoff coronary ostium height of 10 mm and SOVd of 30.5 mm.ConclusionsThree-dimensional modeling has the potential to enable more patients to be safely treated with transcatheter aortic valve replacement who have a low-lying coronary ostium or small SOVd. DLC/d is more predictive of obstruction than coronary ostium height and SOVd.
| S-EPMC6859205 | biostudies-literature
Project description:Coronary obstruction during or after transcatheter aortic valve replacement is a rare and catastrophic sequela that occurs most frequently just after valve implantation. Even rarer is the delayed clinical presentation, in some few patients, of coronary obstruction on the day after self-expandable valve implantation. Here we describe a case of balloon-expandable (not self-expandable) transcatheter aortic valve replacement, followed by partial obstruction of the left main coronary artery on the day after that procedure in a 93-year-old man, despite normal left ventricular contraction just after valve implantation. Visual evaluation of the echocardiogram for left ventricular wall motion was not sufficient, by itself, to achieve early diagnosis of the obstruction. We performed emergency percutaneous coronary intervention. Ninety days after the procedure, the patient was in New York Heart Association functional class I.
| S-EPMC5067043 | biostudies-literature
Project description: Not available
| S-EPMC10512008 | biostudies-literature
Project description:Coronary artery obstruction is an uncommon but devastating complication of transcatheter aortic valve replacement (TAVR). Computed tomography appears to be a sensitive but nonspecific predictor of coronary artery obstruction. Transcatheter approaches to prevent and treat coronary artery obstruction, such as "snorkel" stenting, are unsatisfactory because of serious early and late ischemic complications. Bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction during TAVR (BASILICA) is an early-stage transcatheter procedure to prevent coronary artery obstruction. It works by splitting the native or bioprosthetic leaflets so that they splay after TAVR and preserve coronary artery inflow. Because of the paucity of suitable alternatives, there is interest in the BASILICA technique despite its infancy. This tutorial review summarizes current thinking about how to predict and prevent coronary artery obstruction using BASILICA. First, the authors depict the main pathophysiological mechanisms of TAVR-associated coronary artery obstruction, along with the factors thought to contribute to coronary obstruction. Next, the authors provide a step-by-step guide to analyzing pre-procedural computed tomographic findings to assess obstruction risk and, if desirable, to plan BASILICA. Next, the authors describe the mechanisms underlying transcatheter electrosurgery. Finally, they provide step-by-step guidance on how to perform the procedure, along with a required equipment list.
| S-EPMC6724191 | biostudies-literature
Project description:ObjectivesThis study sought to develop a novel technique called bioprosthetic or native aortic scallop intentional laceration to prevent coronary artery obstruction (BASILICA).BackgroundCoronary artery obstruction is a rare but fatal complication of transcatheter aortic valve replacement (TAVR).MethodsWe lacerated pericardial leaflets in vitro using catheter electrosurgery, and tested leaflet splaying after benchtop TAVR. The procedure was tested in swine. BASILICA was then offered to patients at high risk of coronary obstruction from TAVR and ineligible for surgical aortic valve replacement. BASILICA used marketed devices. Catheters directed an electrified guidewire to traverse and lacerate the aortic leaflet down the center line. TAVR was performed as usual.ResultsTAVR splayed lacerated bovine pericardial leaflets. BASILICA was successful in pigs, both to left and right cusps. Necropsy revealed full length lacerations with no collateral thermal injury. Seven patients underwent BASILICA on a compassionate basis. Six had failed bioprosthetic valves, both stented and stent-less. Two had severe aortic stenosis, including 1 patient with native disease, 3 had severe aortic regurgitation, and 2 had mixed aortic valve disease. One patient required laceration of both left and right coronary cusps. There was no hemodynamic compromise in any patient following BASILICA. All patients had successful TAVR, with no coronary obstruction, stroke, or any major complications. All patients survived to 30 days.ConclusionsBASILICA may durably prevent coronary obstruction from TAVR. The procedure was successful across a range of presentations, and requires further evaluation in a prospective trial. Its role in treatment of degenerated TAVR devices remains untested.
| S-EPMC6309616 | biostudies-literature
Project description:ObjectivesThis study sought to determine the safety of the BASILICA (bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction) procedure.BackgroundTranscatheter aortic valve replacement causes coronary artery obstruction in 0.7% of cases, with 40% to 50% mortality. BASILICA is a procedure to prevent coronary obstruction. Safety and feasibility in a large patient cohort is lacking.MethodsThe international BASILICA registry was a retrospective, multicenter, real-world registry of patients at risk of coronary artery obstruction undergoing BASILICA and transcatheter aortic valve replacement. Valve Academic Research Consortium-2 definitions were used to adjudicate events.ResultsBetween June 2017 and December 2020, 214 patients were included from 25 centers in North America and Europe; 72.8% had bioprosthetic aortic valves and 78.5% underwent solo BASILICA. Leaflet traversal was successful in 94.9% and leaflet laceration in 94.4%. Partial or complete coronary artery obstruction was seen in 4.7%. Procedure success, defined as successful BASILICA traversal and laceration without mortality, coronary obstruction, or emergency intervention, was achieved in 86.9%. Thirty-day mortality was 2.8% and stroke was 2.8%, with 0.5% disabling stroke. Thirty-day death and disabling stroke were seen in 3.4%. Valve Academic Research Consortium-2 composite safety was achieved in 82.8%. One-year survival was 83.9%. Outcomes were similar between solo and doppio BASILICA, between native and bioprosthetic valves, and with the use of cerebral embolic protection.ConclusionsBASILICA is safe, with low reported rates of stroke and death. BASILICA is feasible in the real-world setting, with a high procedure success rate and low rates of coronary artery obstruction.
| S-EPMC8142224 | biostudies-literature
Project description:BackgroundDelayed coronary artery occlusion (CAO) is a rare but fatal complication after transcatheter aortic valve replacement, chimney stenting is the standard technique for established CAO or impending CAO.Case presentationWe describe a female patient who developed non-ST elevation myocardial infarction after receiving transcatheter aortic valve replacement and chimney stenting 4 months prior. An angiogram revealed delayed coronary artery occlusion with a deformed stent, which was never reported. This patient was subsequently treated with a new chimney stent.ConclusionsFor self-expanding valves, the coronary ostium is protected by chimney stenting, delayed coronary artery occlusion can occur and cause catastrophic complications.
| S-EPMC8447508 | biostudies-literature
Project description: Not available
| S-EPMC7219302 | biostudies-literature
Project description:Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) is emerging as an effective treatment for patients with symptomatically failing bioprosthetic valves and a high prohibitive surgical risk; a longer life expectancy has led to a higher demand for these valve reinterventions due to the increased possibilities of outliving the bioprosthetic valve's durability. Coronary obstruction is the most feared complication of valve-in-valve (ViV) TAVR; it is a rare but life-threatening complication and occurs most frequently at the left coronary artery ostium. Accurate pre-procedural planning, mainly based on cardiac computed tomography, is crucial to determining the feasibility of a ViV TAVR and to assessing the anticipated risk of a coronary obstruction and the eventual need for coronary protection measures. Intraprocedurally, the aortic root and a selective coronary angiography are useful for evaluating the anatomic relationship between the aortic valve and coronary ostia; transesophageal echocardiographic real-time monitoring of the coronary flow with a color Doppler and pulsed-wave Doppler is a valuable tool that allows for a determination of real-time coronary patency and the detection of asymptomatic coronary obstructions. Because of the risk of developing a delayed coronary obstruction, the close postprocedural monitoring of patients at a high risk of developing coronary obstructions is advisable. CT simulations of ViV TAVR, 3D printing models, and fusion imaging represent the future directions that may help provide a personalized lifetime strategy and tailored approach for each patient, potentially minimizing complications and improving outcomes.
| S-EPMC10219453 | biostudies-literature