TAVR Complicated By Anomalous Coronary Arteries; Two Case Reports Optimizing Procedural Strategies
Monica Singh, MD, Triston Smith, MD, David Haybron, MD
Wheeling Hospital, Wheeling, WV, USA
BACKGROUND - Transcatheter aortic valve replacement (TAVR) is a well- established therapeutic option in patients with severe aortic stenosis (AS). Anomalous coronary artery anatomy is increasingly being recognized prior to intervention as routine 3-dimensional reconstructed computed tomographic imaging is used as part of pre-procedural planning (MDCT). Coronary artery obstruction during and after TAVR procedure can occur in 0.5-1.0% of individuals. One cause of obstruction can be compression of an anomalous coronary artery during deployment of the TAVR prosthesis. This report outlines critical features of two patient anatomies and strategies used to optimize the procedural approaches for each patient based on features related to the location and anatomic course of their anomalous arteries.METHODS - Preoperative features and clinical course of two patients who underwent TAVR at our institution over a 6-week period are described. Both patients had preoperative evaluation in the high-risk valve clinic including high-resolution computerized tomography, transthoracic echocardiography, transesophageal echocardiography, cardiac catheterization, functional testing and evaluation by one cardiologist and two cardiothoracic surgeons. Anatomic anomalies were further defined by aortography at the time of the intervention.RESULTS - The patients suffered from distinct anatomic anomalies. A patient with an anomalous RCA arising from the left sinus of Valsalva with a course cephalad to and remote from the aortic annulus and had uncomplicated deployment of the TAVR requiring no coronary interventions. A patient with an anomalous and low-lying circumflex coronary artery originating from the right sinus of Valsalva had prophylactic placement of an intracoronary stent and wire, experienced acute coronary occlusion following deployment of the TAVR prosthesis and was successfully treated by positioning and expansion of the stent with return of circumflex artery perfusion and hemodynamic stabilization. Both patients experienced a prompt recovery and discharge home without complications.CONCLUSIONS - In our two clinical cases, we demonstrate two approaches taken to successfully perform transcatheter aortic valve replacement (TAVR) in high-risk and severely symptomatic patients identified to have anomalous coronary anatomy. We specifically demonstrate that selective PCI as needed and TAVR performed concurrently is a feasible option with a tailored strategy providing an optimal approach in these patients.
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