Author + information
- Received April 19, 2016
- Accepted May 5, 2016
- Published online August 8, 2016.
- aCardiology Department, Royal Free Hospital, London, United Kingdom
- bSt Bartholomew’s Hospital, London, United Kingdom
- ↵∗Reprint requests and correspondence:
Dr. Christopher J. Broyd, Royal Free Hospital, Pond Street, London NW3 2QG, United Kingdom.
An 86-year-old woman presented with chest pain and inferior ST-segment elevation. Her history included coronary artery bypass grafting, percutaneous coronary intervention, and a stroke. She had also undergone transcatheter aortic valve replacement with implantation of a 25-mm Direct Flow Medical (DFM) aortic valve prosthesis 3 years earlier. We proceeded urgently to angiography using a femoral artery approach. The presence of the Direct Flow Medical prosthesis hindered our ability to engage the left main stem, but we achieved appropriate images with nonselective angiography. An ostial left main stem lesion and a moderate circumflex lesion were noted. We also identified a patent left internal mammary artery and a blocked vein graft.
Despite using a number of catheters, we were unable to selectively cannulate the right coronary artery. Eventually a nonselective injection into the space between the upper ring of the prosthesis and the sinus ridge resulted in slow filling of the vessel. The right coronary sinus was also closed off by the valve’s proximal ring, leaving a slitlike channel for perfusion into the vessel, with a large thrombus extending proximally (Figures 1 and 2, Online Videos 1, 2, 3, 4, 5, and 6). Given our highly limited access to this artery, we opted to treat this with intravenous abciximab, which achieved successful electrocardiographic resolution. The patient was discharged 4 days later. We also ascertained that thrombus had been noted on the valve 3 months after implantation at the time of her stroke, after which she had undergone 2 years of anticoagulation.
The DFM valve is a third-generation transcatheter aortic valve replacement device that has advantages in terms of repositionability and low paravalvular leak rates. However, it has a bulky proximal ring and a continuous covering of the frame, which may effectively seal off the coronary sinus (Online Videos 1, 2, 3, 4, 5, and 6) and, as demonstrated here, increases the risk for coronary complications and may impede intervention.
For supplemental videos, please see the online version of this article.
Dr. Mullen has reported that he received research grants from Direct Flow Medical and Edwards Lifesciences and is a consultant for Edwards Lifesciences and Boston Scientific. Drs. Broyd and Shiu have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received April 19, 2016.
- Accepted May 5, 2016.
- American College of Cardiology Foundation