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Left Main Coronary Protection During Transcatheter Aortic Valve Implantation
Tony R. de Carvalho, MD1, Alfredo M. da Rocha Neto, MD
2, Henrique H. Petrillo, MD
2;
1HMilACG - Campo Grande Military Hospital, Campo Grande - MS, Brazil,
2HEMOVIDA - Cardiovascular Intervention Institute, Campo Grande - MS, Brazil
BACKGROUND: In spite of all the benefits and technical advances, Transcatheter aortic valve implantation (TAVI) is still associated with potential serious complications. Acute coronary occlusion is a life-threating complication that must be estimated and prevented with accurate procedure planning. We aimed to demonstrate the planning and performing of a challenging case involving additional risks to the usual TAVI procedure.
METHODS: We report a case of an 80-year-old fragile woman admitted for chest pain, dyspnea (NYHA functional Class III) and an onset of atrial fibrillation with left bundle branch block (LBBB). Echocardiography examination showed aortic stenosis with valve area 0.45 cm2, mean gradient 45mmHg, peak gradient 67 mmHg, and preserved left ventricular function. Angiography examination revealed no critical coronary artery stenosis. Computed tomography scans showed reduced high (low take off) of left coronary ostia with a small calcification on the left main coronary artery (Image.1). Due to the high risk of occlusion, a combination with coronary stenting on left coronary was planned.
RESULTS: A previous dilation of the aortic valve with an 18-mm balloon was performed. Through left common femoral artery, a drug-eluting stent (5 x 22 mm) were positioned in left coronary artery, protected by a guide catheter extension sheath to prevent crushing of the stent (Image.2). While protecting stent in position, through right common femoral artery a 26-mm self-expandable TAVI device was advanced across the aortic valve and completely unscrewed. After post-dilation with a 23 mm balloon due to moderate transprosthetic regurgitation, a reduced flow to the left coronary artery was observed (Image.3). A drug-eluting stent (5 x 22 mm) were released in left main (Image.4). Final aortography showed a normal flow to left coronary artery (Image.5). Post procedure echocardiography evaluation showed a good prosthesis function with a mild aortic paravalvular leak. The electrocardiogram showed sinus rhythm with no change in the pre-existing LBBB. The patient was discharged home on the 4th postoperative day, with no post-operative events.
CONCLUSIONS: In the setting of anatomically challenging issues for TAVI, careful and precise planning are mandatory for a safe procedure and to avoid potentially fatal complications.
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