Strategies for Optimizing Procedural Outcomes in Patients with Severe Aortic Stenosis and Anomalous Coronary Anatomy
David M. Haybron, Triston Smith, MD, Monica Singh, 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 several 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 five patients who underwent aortic valve replacement at our institution over a one year period are described. All 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 cardiologists and cardiothoracic surgeons. Anatomic anomalies were further defined by aortography at the time of the intervention. RESULTS: The patients had 2 basic anatomic anomalies. 3 patients patients with anomalous RCA arising from near the left-right coronary commisure with a course cephalad to and remote from the aortic annulus and had uncomplicated deployment of the TAVR (2) and minimally invasive surgical aortic valve replacement (1) requiring no coronary interventions. Two patients with an anomalous and low-lying circumflex coronary artery originating from the right sinus of Valsalva; one patient had TAVR with 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. The second anomalous circumflex patient underwent minimally invasive SAVR due to young age and patient preference with care taken to avoid injury to the anomalous branch during creation and closure of aortotomy. All five patients experienced a prompt recovery and discharge home without complications. CONCLUSIONS: A tailored approach towards management of patients with severe aortic stenosis and anomalous coronary anatomy permits optimal clinical outcomes and low-lying anomalous coronary arteries may require pre-procedural plans for PCI in deployment of TAVR prosthesis.