Author + information
- Received July 8, 2009
- Revision received October 28, 2009
- Accepted November 5, 2009
- Published online February 1, 2010.
- Rodrigo Bagur, MD,
- Eric Dumont, MD,
- Daniel Doyle, MD,
- Eric Larose, DVM, MD,
- Jerôme Lemieux, MD,
- Sébastien Bergeron, MD,
- Sylvie Bilodeau, MD,
- Olivier F. Bertrand, MD, PhD,
- Robert De Larochellière, MD and
- Josep Rodés-Cabau, MD⁎ ()
- ↵⁎Reprint requests and correspondence:
Dr. Josep Rodés-Cabau, Quebec Heart and Lung Institute, Laval University, 2725 Chemin Sainte-Foy, G1V 4G5 Quebec City, Quebec, Canada
A frail 85-year-old woman with symptomatic severe aortic stenosis was evaluated for transcatheter aortic valve implantation (TAVI). The Society of Thoracic Surgeons (STS) risk score and the logistic EuroSCORE were 7.2% and 13.3%, respectively. Based on extreme frailty and severe chronic kidney disease, the patient was considered nonsuitable for conventional surgery. Cardiac computed tomography and coronary angiography are shown in Figure 1. Due to calcified and small (<7 mm) ilio-femoral arteries, the procedure was performed by transapical approach (1). A 26-mm Edwards-SAPIEN valve (Edwards Lifesciences, Inc., Irvine, California) was successfully implanted, although the valve was positioned in a high position with respect to the aortic annulus (Online Videos 1, 2, 3, and 4). Twenty-four hours after TAVI, the patient had chest-pain with transient ST-segment changes. A coronary angiography showed significant stenosis of the left main coronary artery (LMCA) and right coronary artery (RCA) ostia secondary to the displacement of the calcified native aortic leaflets toward the coronary ostia (Figs. 2A and 2B, Online Videos 5 and 6). Percutaneous coronary intervention was successfully performed in both LMCA and RCA ostia (Figs. 2C and 2D, Online Videos 7 and 8). A pre-discharge cardiac computed tomography and echocardiography are shown in Figure 3 and Online Video 9, respectively. At 6-month follow-up the patient was in functional class II without cardiovascular events.
LMCA stenosis is a potential complication of TAVI (2,3). This case shows that this complication can affect the 2 coronary ostia and become clinically evident in the sub-acute phase after TAVI. Also, it supports the feasibility of percutaneous coronary intervention through the struts of the implanted valve. The presence of a bulky calcified valve has been recognized as a risk factor for LMCA stenosis after TAVI, especially in those cases with a short distance (<8 mm) between the aortic leaflets and the coronary ostia (3,4). In these cases, dye injection at the time of balloon valvuloplasty might be useful to determine the relation of the extended leaflets to coronary ostia (3).
For supplementary Videos 1 to 9, please see the online version of this article.
Drs. Eric Dumont and Josep Rodés-Cabau are consultants for Edwards Lifesciences, Inc.
- Received July 8, 2009.
- Revision received October 28, 2009.
- Accepted November 5, 2009.
- American College of Cardiology Foundation