Successful management of acute left main coronary occlusion following transcatheter aortic valve implantation: a case report.

BACKGROUND: Transcatheter aortic valve implantation is an established, highly effective procedure in selected patients with severe degenerative aortic valve stenosis at high risk for conventional surgery. CASE PRESENTATION: We report a case of a 74-year-old Caucasian man who had an acute left main occlusion after transcatheter implantation of balloon-expandable valve prosthesis, followed by coronary intervention with successful recanalization. CONCLUSIONS: Acute coronary occlusion is a rare life-threatening complication of transcatheter aortic valve implantation that is poorly predictable and requires immediate diagnosis and treatment.

Combined Surgical and Percutaneous Management of Circumflex Artery Occlusion After Minimally Invasive Mitral Valve Repair.

This report describes a hybrid intervention addressing left circumflex artery occlusion during minimally invasive mitral valve repair. By using a radiopaque Cor-Knot device (LSI Solutions), targeted removal of occluding sutures was achieved, circumventing sternotomy and coronary artery bypass. Real-time coronary angiography provided assessment of procedural success during surgical revision in a hybrid operating room.

Evaluation of Coronary Circulation by 13N-Ammonia Myocardial Perfusion Positron Emission Tomography in Patients with Right Coronary Artery Occlusion Due to Kawasaki Disease.

BACKGROUND: Although occlusion of the right coronary artery (RCA) is common in the remote stages of Kawasaki disease, revascularization of the RCA is challenging in children and is usually managed by observation without intervention. METHODS: Using adenosine-stress 13N-ammonia myocardial perfusion positron emission tomography, we evaluated coronary circulation in 14 patients (12 males) with RCA occlusion to identify ischemia (myocardial flow ratio < 2.0) in the RCA region and examined hemodynamics, cardiac function, and coronary aneurysm diameter. These variables were also compared in patients with/without RCA segmental stenosis (SS). RESULTS: There were five cases of ischemia in the RCA region. RCA myocardial blood flow (MBF) at rest was higher in patients with ischemia than in those without ischemia, but the difference was not significant (1.27 ± 0.21 vs. 0.82 ± 0.16 mL/min/g, p = 0.2053). Nine patients presented with RCA SS, and age at onset of Kawasaki disease tended to be lower in those with SS. The maximum aneurysm diameter of RCA was significantly smaller in patients with SS (10.0 ± 2.8 vs. 14.7 ± 1.6, p = 0.0239). No significant differences in other variables were observed between patients with/without ischemia and SS. CONCLUSIONS: At rest, MBF in the RCA region was relatively well preserved, even in patients with RCA occlusion, and there was no progressive deterioration in cardiac function. Adenosine stress showed microcirculatory disturbances in only half of the patients, indicating that it is reversible in children with Kawasaki disease.

From Atherosclerotic Plaque to Myocardial Infarction-The Leading Cause of Coronary Artery Occlusion.

Cardiovascular disease (CVD) constitutes the most common cause of death worldwide. In Europe alone, approximately 4 million people die annually due to CVD. The leading component of CVD leading to mortality is myocardial infarction (MI). MI is classified into several types. Type 1 is associated with atherosclerosis, type 2 results from inadequate oxygen supply to cardiomyocytes, type 3 is defined as sudden cardiac death, while types 4 and 5 are associated with procedures such as percutaneous coronary intervention and coronary artery bypass grafting, respectively. Of particular note is type 1, which is also the most frequently occurring form of MI. Factors predisposing to its occurrence include, among others, high levels of low-density lipoprotein cholesterol (LDL-C) in the blood, cigarette smoking, chronic kidney disease (CKD), diabetes mellitus (DM), hypertension, and familial hypercholesterolaemia (FH). The primary objective of this review is to elucidate the issues with regard to type 1 MI. Our paper delves into, amidst other aspects, its pathogenesis, risk assessment, diagnosis, pharmacotherapy, and interventional treatment options in both acute and long-term conditions.

Coronary Risk in Transcatheter Aortic Valve Replacement, Overview of Data, Challenges, and Best Practices.

Coronary artery obstruction is a rare complication of transcatheter aortic valve replacement (TAVR). This risk increases in TAVR-valve-in-valve procedure. Several anatomic risk factors were described in many studies to identify the predictive elements of coronary artery occlusion on computed tomography cardiac scan. Rescue percutaneous coronary intervention was the first approach described to treat this complication with a high mortality rate. Later on, preventive chimney stenting technique was evaluated and results showed that is a safe and effective strategy but it leads to a difficult coronary access later. New preventive techniques are being evaluated recently (Basilica and Shorctut).

Impact of commissural versus coronary alignment on risk of coronary obstruction following transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) with commissural alignment aims to limit the risk of coronary occlusion and maintain good coronary access. However, due to coronary origin eccentricity within the coronary cusp, coronary-commissural overlap (CCO) may still occur. TAVI using coronary alignment, rather than commissural alignment, may further improve coronary access. To compare rates of CCO after TAVI using commissural versus coronary alignment methodology. Cardiac CT scans from 102 patients with severe (tricuspid) aortic stenosis referred for TAVI were analysed. Native cusp asymmetry and coronary eccentricity were defined and used to simulate TAVI using commissural versus coronary alignment. Rates of optimal coronary alignment (< 10° from cusp centre) and severe misalignment (< 15° from coronary-commissural overlap) were compared. Additionally, the impact of valve misalignment during implantation was assessed. The native right coronary artery (RCA) origin was 15.8° (9.5 to 24°) closer to the right coronary cusp/non-coronary cusp (RCC-NCC) commissure than the centre of the right coronary cusp. The native left coronary artery (LCA) origin was 4.5° (0 to 11.5°) closer to the left coronary cusp/non-coronary cusp (LCC-NCC) commissure than the centre of the left coronary cusp (p < 0.01). Compared to commissural alignment, coronary alignment doubled the proportion of optimally-aligned RCAs (62/102 [60.8%] vs. 31/102 [30.4%]; p < 0.001), without a significant change in optimal LCA alignment (62/102 [60.8% vs. 74/102 [72.6%]; p = 0.07). There were no cases of severe misalignment with either strategy. Simulating 15° of valve misalignment resulted in severe RCA compromise risk in 7/102 (6.9%) of commissural alignment cases, compared to none using coronary alignment. Fluoroscopic projection was similar with both approaches. Coronary alignment resulted in a 2-fold increase of optimal TAVI positioning relative to the RCA ostium when compared to commissural alignment without impacting the LCA. Use of coronary alignment rather than commissural alignment may improve coronary access after TAVI and is less sensitive to valve rotational error, particularly for the right coronary artery.

Coronary Artery Obstruction After Transcatheter Aortic Valve Implantation: Past, Present, and Future.

Coronary obstruction (CO) is a rare but critical complication of transcatheter aortic valve implantation. It is associated with significant morbidity and mortality. This comprehensive review elucidates the evolving landscape of CO risk assessment and management strategies in the contemporary era of transcatheter aortic valve implantation. Drawing upon recent advances in computed tomography angiography, we delve into the nuanced evaluation of anatomic parameters crucial for predicting CO risk. Furthermore, this review explores the utility of interventional and surgical techniques, including chimney stenting and leaflet modification systems, in mitigating CO complications. In summary, this review serves as a practical guide for clinicians navigating the complexities of CO prevention and management in the evolving landscape of transcatheter aortic valve implantation, with the goal of optimizing patient outcomes and ensuring procedural success.

Leaflet modification with the ShortCut™ device to prevent coronary artery obstruction during TAVR.

Transcatheter heart valve (THV) procedures require careful planning and consideration to prevent coronary artery obstruction (CAO), which poses a significant and potentially life-threatening condition, especially in patients undergoing valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR). Despite identifying predictors of CAO and utilization of computed tomography and inputting THV features, a significant uncertainty remains in predicting CAO. The ShortCut™ device (Pi-Cardia, Rehovot, Israel) was purposefully designed to modify the leaflets in patients undergoing TAVR, especially prior to ViV procedures, to overcome the risk for CAO. This review aims to detail the device's objectives, structure, procedural steps, the available clinical data, and future directions for its intended utilization in the structural arena for the prevention of CAO.

Novel valve-in-surgical bioprosthetic transcatheter aortic valve replacement: Undermining iatrogenic coronary obstruction with radiofrequency needle (UNICORN).

An 86-year-old female with history of surgical aortic valve replacement presented with clinical signs of heart failure. Echocardiography revealed a reduction in left ventricular systolic function and severe bioprosthetic aortic valve dysfunction. This is the first reported case of valve-in-valve transcatheter aortic valve replacement with concomitant undermining iatrogenic coronary obstruction with radiofrequency needle procedure in a surgical bioprosthetic valve.

A case report of ventricular fibrillation following Shockwave intravascular lithotripsy during percutaneous coronary intervention.

BACKGROUND: Shockwave intravascular lithotripsy (S-IVL) is widely used during percutaneous coronary intervention (PCI) of calcified coronary arteries. Ventricular capture beats during S-IVL are common but arrhythmias are rare. CASE PRESENTATION: A 75-year-old woman was scheduled for PCI to a short, heavily calcified chronic total occlusion of the right coronary artery. After wiring of the occlusion, S-IVL was used to predilated the calcified stenosis. During S-IVL, the patient developed ventricular fibrillation twice. CONCLUSION: To our knowledge, this is only the second reported case of VF during S-IVL. Although very rare, it is important to be aware of this potential and serious complication.

Using Ping-pong technique along with rapid inflate-deflate ballooning to solve total left main occlusion during transcatheter aortic valve replacement procedure.

Coronary obstruction during transcatheter aortic valve replacement (TAVR) poses a significant threat, prompting a closer examination of prevention and bailout strategies. Following TAVR deployment with a coronary artery obstruction complication and recognizing the complexities involved in engaging the left main coronary artery through TAVR cells. This case introduces the "Ping-pong" technique using a second guide catheter. When faced with difficulty in engaging the catheter through TAVR cells, an innovative solution is proposed. Inserting a wire into the valsalva and utilizing a rapid inflate-deflate balloon maneuver successfully facilitates catheter access into the left main, offering a promising intervention for challenging scenarios. In conclusion, this study emphasizes the severe implications of coronary obstruction during TAVR. The innovative "Ping-pong" technique and rapid inflate-deflate balloons emerge as valuable interventions, showcasing their potential in challenging catheter engagement scenarios. These insights offer a promising avenue for enhancing patient outcomes in TAVR procedures.

High risk of coronary artery obstruction during TAVR, how to avoid it?

BACKGROUND: Coronary artery obstruction after percutaneous aortic replacement is a complication with high short-term mortality secondary to the lack of timely treatment. There are various predictors of coronary obstruction prior to valve placement such as the distance from the ostia, the degree of calcification, the distance from the sinuses; In such a situation some measures must be taken to prevent and treat coronary obstruction. CASE PRESENTATION: An 84-year-old male, with severe aortic stenosis and high surgical risk, who was treated with TAVR. However, during the deployment of the valve he presented hemodynamic instability secondary to LMCA obstruction. The intravascular image showed obstruction of the ostium secondary to the displacement of calcium that he was successfully treated with a chimney stent technique. CONCLUSIONS: The high degree of calcification and the left ostium near the annulus are conditions for obstruction of the ostium at the time of valve release; In this context, provisional stenting prior to TAVR in patients at high risk of obstruction should be considered as a safe prevention strategy to achieve the success of the procedure.

Chimney Stenting vs BASILICA for Prevention of Acute Coronary Obstruction During Transcatheter Aortic Valve Replacement.

BACKGROUND: Coronary obstruction (CO) is a potentially life-threatening complication of transcatheter aortic valve replacement (TAVR). Chimney stenting or leaflet laceration with transcatheter electrosurgery (Bioprosthetic or Native Aortic Scallop Intentional Laceration to Prevent Iatrogenic Coronary Artery Obstruction [BASILICA]) are 2 techniques developed to prevent CO. OBJECTIVES: The aim of the present study was to compare periprocedural and 1-year outcomes of chimney and BASILICA in TAVR patients at high risk of CO. METHODS: This multicenter observational registry enrolled consecutive TAVR patients at high risk of CO, undergoing either preventive chimney stenting or BASILICA. Clinical success was defined as successful performance of the chimney or BASILICA technique without clinically relevant ostial CO. The primary endpoint was major adverse cardiovascular events, a composite of death, myocardial infarction, stroke, or unplanned target lesion coronary revascularization at 1 year. RESULTS: A total of 168 patients were included: 71 (42.3%) received chimney stenting, and 97 (57.7%) underwent BASILICA. Patients undergoing BASILICA had higher preprocedural risk of CO, as indicated by lower sinotubular junction height (18.2 ± 4.8 mm vs 14.8 ± 3.4 mm; P < 0.001) and diameter (28.2 ± 4.5 vs 26.8 ± 3.4; P = 0.029). Rates of periprocedural complications were similar between the 2 groups. Clinical success was 97.2% and 96.9% in chimney and BASILICA, respectively (P = 0.92). At 1-year follow-up, the cumulative incidence of major adverse cardiovascular events was 18.7% (95% CI: 11%-30.6%) in the chimney group and 19.9% (95% CI: 12.1%-31.5%) in the BASILICA group (log-rank P = 0.848), whereas chimney was associated with a numerically higher cardiovascular mortality than BASILICA (6.7% vs 1.3%; log-rank P = 0.168). CONCLUSIONS: Chimney stenting and BASILICA effectively prevent TAVR-induced acute CO. Both techniques seem to have comparable acceptable periprocedural and 1-year outcomes.

Guide catheter extension use are associated with higher procedural success in chronic total occlusion percutaneous coronary interventions.

BACKGROUND: Guide catheter extensions (GCEs) increase support and facilitate equipment delivery, but aggressive instrumentation may be associated with a higher risk of complications. AIM: Our aim was to assess the impact of GCEs on procedural success and complications in patients submitted to chronic total occlusion (CTO) percutaneous coronary intervention (PCI). METHODS: We analyzed data from the multicenter LATAM CTO Registry. Procedural success was defined as <30% residual stenosis and TIMI 3 distal flow. Major adverse cardiac and cerebrovascular events (MACCE) was defined as the composite of all-cause death, myocardial infarction, target vessel revascularization, and stroke. Propensity score matching (PSM) was used to compare outcomes with and without GCE use. RESULTS: From August 2010 to August 2021, 3049 patients were included. GCEs were used in 438 patients (14.5%). In unadjusted analysis, patients in the GCE group were older and had more comorbidities. The median J-CTO score and its components were higher in the GCE group. After PSM, procedural success was higher with GCE use (87.7% vs. 80.5%, p = 0.007). The incidence of coronary perforation (odds ratio [OR]: 1.46, 95% confidence interval [CI]: 0.78-2.71, p = 0.230), bleeding (OR: 1.99, 95% CI: 0.41-2.41, p = 0.986), in-hospital death (OR: 1.39, 95% CI: 0.54-3.62, p = 0.495) and MACCE (OR: 1.07, 95% CI: 0.52-2.19, p = 0.850) were similar in both groups. CONCLUSION: In a contemporary, multicenter cohort of patients undergoing CTO PCI, GCEs were used in older patients, with more comorbidities and complex anatomy. After PSM, GCE use was associated with higher procedural success, and similar incidence of adverse outcomes.

Coronary Aneurysm after Excimer Laser Catheter Ablation and Plain Balloon Angioplasty for Chronic Total Occlusion in a Patient with Kawasaki Disease.

A 37-year-old man with a history of Kawasaki disease presented with total occlusion of the right coronary artery. The patient underwent percutaneous coronary intervention (PCI) with excimer laser coronary angioplasty (ELCA) and plain old balloon angioplasty (POBA). Three months after PCI, a coronary aneurysm with restenosis was detected at the PCI site, and PCI was performed again using a small balloon. The aneurysm healed three months after the second PCI procedure. This is the first report describing the long-term outcome after an aneurysm caused by PCI with ELCA and POBA.

Thick endothelialization of the self-expandable valve causes delayed coronary obstruction.

Delayed coronary obstruction is a rare complication occurring after transcatheter aortic valve replacement (TAVR). Although TAVR has become popular, in some cases, the therapeutic strategy should be carefully selected depending on the patient's anatomical and/or functional restrictions. We report a rare case of delayed coronary obstruction in which coronary obstruction was caused by thick endothelialization of the nitinol frame of the prosthetic valve. A 79-year-old female who had undergone TAVR 4 months before presented with mild chest pain and was admitted to our institution. Computed tomography and coronary angiography revealed that the space from the sinus of Valsalva to the nitinol frame was narrow and separated from the inside of the nitinol frame because of critical endothelialization. Therefore, an emergency surgical aortic valve replacement was performed. The patient had an uneventful postoperative course and was discharged 20 days postoperatively without any complications.