Transcatheter pulmonary valve replacement after arterial switch operation.

BACKGROUND: Patients with d-transposition of the great arteries (d-TGA) who have undergone an arterial switch operation (ASO) can develop right ventricular outflow tract (RVOT) dysfunction with pulmonary regurgitation (PR) or stenosis. In these patients, treatment may include transcatheter pulmonary valve replacement (TPVR). Coronary compression is a contraindication occurring in 5% of typical TPVR cases. After ASO, there are various anatomical considerations that can confound TPVR, including potential coronary artery compression. Our goal is to understand feasibility of TPVR in patients following ASO. METHODS: This was a retrospective multicenter cohort study of patients with RVOT dysfunction after ASO who underwent cardiac catheterization with intention to perform TPVR from 2008 to 2020. RESULTS: Across nine centers, 33 patients met inclusion criteria. TPVR was successful in 22 patients (66%), 19 receiving a Melody valve and 3 a SAPIEN valve. RVOT stenosis in isolation or with PR dictated need for TPVR in nearly all patients. One serious adverse event occurred with valve embolization. After TPVR, the RVOT peak gradient decreased from 43 to 9 mm Hg (p < 0.001); PR was trivial/none in all but one patient, in whom it was mild. Coronary compression prohibiting TPVR occurred in eight patients (24%) and two patients (6%) had severe aortic regurgitation from aortic root deformation precluding TPVR. Seven patients underwent RVOT reintervention with a median of 5.3 years post-TPVR. CONCLUSIONS: TPVR in patients with d-TGA after ASO is feasible, but in this cohort, coronary compression or aortic root distortion precluded TPVR in one-third of patients. The rate of RVOT reintervention after TPVR was higher in this cohort of ASO patients that in prior studies.

Extrinsic compression of left main coronary artery due to pulmonary artery aneurysm and pulmonary hypertension.

Idiopathic pulmonary arterial hypertension is a serious condition that carries a poor prognosis. While exertional dyspnea is the most common symptom, angina like chest pain, most often due to right ventricle ischemia, may occur at advanced stages. We present a patient with pulmonary hypertension symptomatic for dyspnea and angina in whom computed coronary tomography angiography showed compression of the left main coronary artery by a large pulmonary artery aneurysm. Percutaneous coronary intervention and stenting was performed resulting in significant clinical improvement. This case emphasizes the role of different cardiovascular imaging modalities for the diagnosis of rare conditions.

Exertional Angina in a Young Woman Caused by Large Cardiac Paraganglioma.

Coronary ischemia is uncommon in patients in their third decade of life. We present a 21-year-old woman with classic exertional angina secondary to a large cardiac paraganglioma. Cardiac paragangliomas are rare extra-adrenal neuroendocrine tumors that arise from chromaffin cells. Cardiac symptoms can be related to catecholamine excess or anatomical compression.

Surgical management of a giant pulmonary artery aneurysm in a patient with ischaemic heart disease - a case report.

Association of Pulmonary Artery Aneurysm with Ischemic Heart Disease is uncommon, and its surgical management has been rarely described in the literature. Surgical intervention should be individualised according to the coexisting diseases and comorbidities to achieve optimal outcome. We report a case of a 76-year-old man with background history of coronary artery stenting due to ischaemic heart disease. The patient presented with features of coronary compression due to giant pulmonary artery aneurysm. He was operated with replacement of aneurysmal pulmonary trunk with 25 mm Hancock conduit.

Evaluation of patients for potential compression of anomalous coronaries coursing behind the aortic root before device closure of secundum atrial septal defects.

Coronary arteries coursing behind the aortic root may get compressed when nitinol septal occluders are used to close an atrial septal defect. Hence, echocardiographic recognition of a retroaortic linear vessel is important during preinterventional evaluation. While the left circumflex arising from the right coronary artery is the most common cause, a similar finding is sometimes observed in a single left or right coronary artery and rarely with small sinus nodal branches from the left circumflex artery. Complex three-dimensional relations between the defect and the aortic root may be understood only after a postdeployment selective coronary angiography. Two patients with anomalous retroaortic left circumflex from the right coronary artery underwent uneventful device closure with clearly documented separation between the edges of the occluder and the anomalous vessel. Follow-up imaging and exercise testing confirmed the safety of the intervention. A selective postdeployment and postrelease coronary angiography are mandatory in every patient with retroaortic coronaries.

A case of acute myocardial infarction due to coronary artery compression by mediastinal hematoma associated with thoracic aortic aneurysm rupture.

A 76-year-old woman was admitted to our department for pneumonia. Although she gradually recovered, she complained of chest and back pain and went into shock. Electrocardiogram showed ST-segment elevation in the inferior leads; thus, an acute inferior myocardial infarction (MI) was strongly suspected. Emergent coronary angiography revealed subtotal right coronary artery (RCA) occlusion, and intravascular ultrasound showed flattening of the RCA ostium. Although the coronary artery flow improved after percutaneous coronary intervention with rescue stent implantation, the patient was still in a prolonged state of shock. Contrast-enhanced computed tomography revealed a ruptured thoracic aortic aneurysm (TAA) with a massive posterior mediastinal hematoma. We presumed that the acute MI and shock were caused by compression of the RCA ostium by the mediastinal hematoma and hemorrhage with TAA rupture, respectively. The patient was urgently transferred to another hospital for surgery. To the best of our knowledge, there has been no report on acute MI due to coronary artery compression by a mediastinal hematoma associated with TAA rupture. A staged therapeutic approach, involving preoperative coronary stent implantation, could be used to save the patient. .

Coronary Compression Following Percutaneous Pulmonary Valve Implantation Despite a Negative Balloon Sizing Test: Lessons Learnt From This Unusual Complication.

A 16-years-old male with prior diagnosis of situs inversus totalis and pulmonary atresia with interventricular communication underwent percutaneous pulmonary valve implantation 3 months after successful RVOT stenting following a negative balloon sizing test. Once finished the procedure, after consciousness recovery in the intensive care unit, the patient developed oppressive chest pain with very subtle electrocardiographic changes over his basal right bundle branch block. An urgent coronary angiography showed a severe stenosis in the proximal right coronary artery with TIMI 2 distal flow. Intravascular ultrasound imaging confirmed extrinsic compression. A 4 × 21 mm drug-eluting stent was successfully implanted relieving symptoms immediately. TIMI 3 flow was restored and good apposition and expansion were confirmed with intravascular ultrasound. A carefully review of the procedure showed that the pitfall responsible for this complication was the oversizing of the valve with respect to the size of the balloon used for the sizing test.

Acute coronary syndrome caused by extrinsic coronary compression from an aortic root abscess in a patient with mechanical aortic valve endocarditis: a case report and literature review.

BACKGROUND: Extrinsic coronary compression is an extremely rare complication of aortic root abscess formation and can manifest as an acute coronary syndrome in infective endocarditis. Optimal management strategies are unknown and therefore illustrative case reports may be informative. CASE SUMMARY: We describe a 63-year-old man with a background history of a mechanical aortic valve who developed sepsis due to Escherichia coli bacteraemia from a presumed urinary source. He suddenly deteriorated with cardiogenic shock and anterior ST-segment elevation myocardial infarction on Day 16 and received emergency percutaneous coronary intervention for severe stenoses of left anterior descending and diagonal arteries. A transoesophageal echocardiogram 2 days later demonstrated a large aortic root abscess. He was transferred for emergency surgery which revealed a large aortic abscess surrounding the left main stem confirming extrinsic coronary compression. He received a redo tissue aortic valve replacement and repair of his abscess cavity. DISCUSSION: We describe a case where percutaneous coronary intervention and emergency surgery was used to treat extrinsic compression from an aortic root abscess; a complication that is associated with a high mortality. This is also a rare case of E. coli causing prosthetic valve endocarditis. We also explore the findings of 11 previous cases of extrinsic coronary compression from aortic root abscess.

Coronary compression testing by balloon interrogation during pulmonary valve implantation: room for doubt?

OBJECTIVE: To evaluate the reliability of balloon coronary compression testing during percutaneous pulmonary valve implantation. BACKGROUND: Despite the widespread use of the 'balloon coronary test' as the preferable method to rule out the risk of coronary compression, this adverse event has been described after pulmonary valve implantation where coronary balloon test suggested no risk or low risk, calling into question the accuracy of the test. METHODS: We performed a retrospective chart review of 84 patients who underwent pulmonary valve implantation between January 2018 and December 2019 and selected 36 patients whose archived imaging was suitable to perform quantitative analysis of the 'balloon coronary test'. We focused on the spatial disparity between the right ventricular outflow tract position defined by the inflated testing balloon and the eventual implanted valve position, to classify the test as inaccurate or accurate. RESULTS: In total, 36.1% of cases were classified as having an inaccurate coronary balloon test. Among the baseline characteristics, right ventricular outflow tract substrate was identified as a significant predictor of test accuracy. Related to this characteristic, the type of testing balloon used and the size of the eventually implanted valve were found to be associated with test accuracy. CONCLUSIONS: Based on our findings, balloon coronary testing is not an accurate method of predicting final valve position with respect to fixed structures in the thorax. This may translate to a high false positive rate for the likelihood of coronary compression in pulmonary valve implantation.

Large sub-mitral aneurysm compressing the left circumflex coronary artery presenting with atypical chest pain - Rare presentation.

Sub-mitral aneurysm (SMA) is a rare cardiac malformation commonly reported in young adults of African ancestry. SMA is considered a congenital disease caused by developmental defect due to weakness at the atrioventricular junction near the posterior mitral annulus. In the past two decades, a considerable number of cases regarding this rare disease have been reported in Asians, highlighting the importance of considering SMA in differential diagnosis of young patients presenting with mitral regurgitation and chest pain. Herein, we report the case of a young male with atypical chest pain with compression of left circumflex coronary artery by a large SMA. .

Utility of CT Angiography for the Prediction of Coronary Artery Compression in Patients Undergoing Transcatheter Pulmonary Valve Replacement.

OBJECTIVES: We aimed to evaluate the utility of computed tomography angiography (CTA) for coronary compression (CC) prediction in patients with congenital heart disease undergoing balloon-expandable transcatheter pulmonary valve replacement (TPVR). BACKGROUND: Coronary compression is a serious complication of TPVR, but the value of preprocedural CTAs to assess CC risk is largely unexplored. METHODS: In all, 586 patients underwent TPVR between January 2009 and July 2018. Adults with a pre-TPVR CTA and children with a CTA performed less than one year prior to TPVR were included. Patients with poor CTA image quality or with aborted cases due to reasons other than CC were excluded. Sixty-six patients were finally included. Cardiac anatomy was assessed via multiplanar reconstruction of CTAs. RESULTS: Coronary compression occurred in 9 (14%) of the 66 patients who underwent TPVR. Most CC cases (seven of nine) occurred in patients with conduits. Proximity of the right ventricular outflow tract (RVOT) landing zone to the coronary arteries and to the chest wall was a significant risk factor for compression (P < .001 and P = .019, respectively). Compression risk increased significantly if patients had an RVOT to coronary artery distance of ≤3 mm (P < .001) and an RVOT to chest wall distance of ≤8 mm (P = .026). Anomalous course of coronary arteries was another significant univariate risk factor (P = .003). CONCLUSIONS: Right ventricular outflow tract landing zone distance of ≤3 mm to a coronary artery, landing zone distance of ≤8 mm to the chest wall, and anomalous coronary arteries are associated with increased CC risk. Electrocardiogram gating may not be necessary if coronary arteries are opacified on CTAs. Larger studies are needed to explore and confirm these coronary artery compression risk factors.

Cangrelor use in a 6-year-old patient undergoing complex percutaneous coronary intervention after post-surgical myocardial infarction.

Cangrelor is an intravenously administered P2Y12 receptor antagonist, which has been approved for adult patients undergoing percutaneous coronary intervention and, due to its unique pharmacokinetics, it allows effective and controllable peri-procedural platelet inhibition. We report the case of a 6-year-old child with anomalous origin of right coronary artery from aortic left coronary sinus, who underwent elective surgical replacement of stenotic and calcified conduit between the right ventricle and the main pulmonary artery. The surgery was complicated by acute myocardial infarction secondary to coronary extrinsic compression. The patient was successfully treated with urgent percutaneous coronary intervention (simultaneous V-stenting) and cangrelor infusion, subsequently switched to clopidogrel therapy.

Cardiac CT to assess the risk of coronary compression in patients evaluated for percutaneous pulmonary valve implantation.

BACKGROUND: Coronary compression (CC) is a life threatening complication that can occur during percutaneous pulmonary valve implantation (PPVI). We describe our experience using cardiac CT prior to PPVI to identify patients at high CC-risk due to a close relationship between the coronary arteries and pulmonary trunk (PT). METHODS: A retrospective evaluation of candidates for PPVI who underwent CT prior to the procedure was done. Measurements of PT were performed using double oblique reconstructed images, with special attention to the stenotic tract of the PT. The analysis of coronary arteries included detection of anomalies of origin and course and assessment of their relationship with the PT, measuring the minimum distance between the coronary artery and the intended site of the future percutaneous valve implantation. RESULTS: CT analysis was performed for 52 patients. Thirty patients underwent PPVI after CT and 22 didn't. In 6/22 cases the reason not to receive a PPVI was high CC-risk detected at CT. In 6 other patients CT detected an intermediate CC-risk but the test balloon performed during angiography prior to valve placement was safe and the patients successfully underwent the procedure. None of the patients deemed as no CC-risk at CT had CC during PPVI. CONCLUSION: CT can detect patients with high and intermediate CC-risk and therefore may identify which patients are unlikely to undergo successful PPVI and those who need a careful analysis with balloon testing. CT can also rule out CC-risk identifying those patients in which balloon inflation testing could be omitted.

Percutaneous pulmonary valve implantation in patients after Ross procedure: role of intravascular ultrasound.

Coronary compression exclusion during right ventricle outflow tract stenting is recommended and potential oversight may be fatal. Balloon inflation in right ventricle outflow tract with simultaneous aortography can be inconclusive or falsely negative. We present a case of 27-year-old male post Ross operation qualified for percutaneous pulmonary valve implantation. Neither of the conventional views obtained provided a definite exclusion of coronary compression, therefore an intravascular ultrasound of the left coronary artery before and during balloon inflation in right ventricle outflow tract was performed. Acquired images allowed excluding potential constriction, thus a covered stent and pulmonary valve were implanted and the procedure was concluded. Two hours later, the patient complained of chest pain. Transthoracic echocardiography demonstrated a significant pericardial effusion. Retrospective analysis of the final angiogram revealed a possibility of subtle extravasation at the distal part of the homograft. A hybrid procedure consisting of additional covered stent implantation, pericardial drainage, and second pulmonary valve implantation was performed with an acceptable result. To conclude, in case of doubtful or unconvincing images obtained from aortography or selective angiography during balloon inflation in right ventricle outflow tract, intravascular ultrasound might be a feasible and useful technique. Signs of homograft rupture may be subtle, whereas symptoms of cardiac tamponade delayed. In selected patients percutaneous treatment of homograft rupture is achievable and beneficial.

Preprocedural Risk Assessment Prior to PPVI with CMR and Cardiac CT.

Percutaneous pulmonary valve intervention (PPVI) is a less invasive and less costly approach to pulmonary valve replacement compared with the surgical alternative. Potential complications of PPVI include coronary compression and pulmonary arterial injury/rupture. The purpose of this study was to characterize the morphological risk factors for PPVI complication with cardiac MRI and cardiac CTA. A retrospective review of 88 PPVI procedures was performed. 44 patients had preprocedural cardiac MRIs or CTAs available for review. Multiple morphological variables on cardiac MRI and CTA were compared with known PPVI outcome and used to investigate associations of variables in determining coronary compression or right ventricular-pulmonary arterial conduit injury. The most significant risk factor for coronary artery compression was the proximity of the coronary arteries to the conduit. In all patients with coronary compression during PPVI, the coronary artery touched the conduit on the preprocedural CTA/MRI, whilst in patients without coronary compression the mean distance between the coronary artery and the conduit was 4.9 mm (range of 0.8-20 mm). Multivariable regression analysis demonstrated that exuberant conduit calcification was the most important variable for determining conduit injury. Position of the coronary artery directly contacting the conduit without any intervening fat may predict coronary artery compression during PPVI. Exuberant conduit calcification increases the risk of PPVI-associated conduit injury. Close attention to these factors is recommended prior to intervention in patients with pulmonary valve dysfunction.

Three dimensional rotational angiography for assessment of coronary arteries during melody valve implantation: introducing a technique that may improve outcomes.

BACKGROUND: Adverse events from Melody valve implantation may be catastrophic. To date a role for three dimensional rotational angiography of the aortic root (3DRAA) during Melody valve implantation has not been established. OBJECTIVES: To describe the role of 3DRAA in the assessment of Melody valve candidacy and to demonstrate that it may improve outcomes. METHODS: All patients who underwent cardiac catheterisation for Melody valve implantation and 3DRAA between August 2013 and February 2015 were reviewed. RESULTS: 31 patients had 3DRAA with balloon sizing. Ten were deemed not Melody candidates (5 coronary compression, 2 aortic root distortion with cusp flattening, 2 RVOT was too large, and 1 had complex branch stenosis and a short landing zone). Of the 21 patients who were Melody candidates, 12 had conduits, 6 prosthetic valves and 3 native RVOTs. In patients with conduits, the technique of stenting the conduit prior to dilation was used after measuring the distance between the conduit and the coronary arteries on 3DRAA. In the Melody patients, we had 100% procedural success and no serious adverse events (coronary compression, tears, stent fracture or endocarditis). CONCLUSION: As a tool for case selection, 3DRAA may facilitate higher procedural success and decreased risk of serious adverse events. Furthermore, 3D rotational angiography allows stenting of the conduit prior to dilation, which may prevent tears and possibly endocarditis.

Dynamic Systolic Compression of the Left Anterior Descending Coronary Artery by a Postinfarction Dyskinetic Left Ventricular Aneurysm.

Dynamic systolic compression of the coronary arteries is almost always due to the existence of myocardial bridging that is most commonly localized in the middle segment of the left anterior descending coronary artery. However, it has rarely been reported in patients with pericardial adhesions, tumor, foreign body, or pseudoaneurysms. Only rare case reports exist regarding dynamic coronary compression by a dyskinetic left ventricular aneurysm. We present a patient with a myocardial bridge-like systolic compression of the distal left anterior descending caused by postinfarction dyskinetic left ventricular aneurysm.