Author + information
- Received January 15, 2015
- Revision received February 18, 2015
- Accepted March 2, 2015
- Published online August 24, 2015.
- Peter Lugomirski, MD∗∗ (, )
- Brian McArdle, MB, BCh∗,
- Aiman Alak, MD†,
- Alexander Dick, MD∗ and
- Marino Labinaz, MD∗
- ∗Department of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- †Department of Cardiology, McMaster University, Hamilton, Ontario, Canada
- ↵∗Reprint requests and correspondence:
Dr. Peter Lugomirski, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario K1Y 4W7, Canada.
An 87-year-old female patient had an uncomplicated Medtronic CoreValve transcatheter aortic valve replacement (TAVR) (Medtronic, Minneapolis, Minnesota) (Figure 1, Online Video 1). The 29-mm CoreValve was correctly sized on the basis of the annulus perimeter, aortic sinus, and ascending aorta. One year later, she presents with a 15-min episode of chest pain at rest with global transient ST-segment depression and elevated troponin-I. She also reports angina during hemodialysis, which was initiated after a complicated right hemi-colectomy 6 months before. Coronary angiogram before TAVR showed normal coronary arteries.
She underwent a Rubidium-82 positron emission tomography perfusion scan, which demonstrated moderate-to-severe left anterior descending artery and circumflex ischemia. Computed tomography coronary angiography demonstrated that the bioprosthetic valve cusps were above the origin of the left main with the valve struts impinging the left coronary sinus of Valsalva (Figure 2).
A repeat angiogram demonstrated that there were no significant coronary stenoses and there was no migration of the CoreValve. The left coronary ostium was below the plane of the bioprosthetic leaflets, and the amount of paravalvular filling of the left coronary artery was reduced because of narrowing at the sinus of Valsalva (Figure 3, Online Video 2). Therefore, when the patient’s blood pressure decreased (e.g., during hemodialysis) she developed reduced coronary blood flow and cardiac ischemia.
Left main obstruction has been previously described post-TAVR (1,2); however, these patients developed ischemia immediately post-implantation. This is the first case of left main impingement presenting with ischemia at 1-year post-implantation.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received January 15, 2015.
- Revision received February 18, 2015.
- Accepted March 2, 2015.
- 2015 American College of Cardiology Foundation