Author + information
- Received October 30, 2017
- Revision received December 6, 2017
- Accepted January 2, 2018
- Published online April 18, 2018.
- Matthew S. Glassy, MD∗ (, )
- Jeffrey A. Southard, MD,
- Benjamin R. Stripe, MD and
- Reginald I. Low, MD
- Division of Cardiovascular Medicine, University of California Davis Medical Center, Sacramento, California
- ↵∗Address for correspondence:
Dr. Matthew S. Glassy, Division of Cardiovascular Medicine, University of California Davis Medical Center, 4860 Y Street, Suite 2820, Sacramento, California 95817.
- left aortic leaflet
- left main thrombosis
- Lotus valve
- percutaneous coronary intervention
- transcatheter aortic valve replacement
An 89-year-old woman with severe symptomatic aortic valve stenosis and poor surgical candidacy underwent transcatheter aortic valve replacement (TAVR) with a 23-mm Lotus valve (Boston Scientific, Marlborough, Massachusetts). Preoperative computed tomography demonstrated aortic sinuses and coronary heights that were smaller and lower than was ideal but not completely exclusionary for TAVR (Figures 1A to 1D). The virtual valve to coronary distance was 3.7 mm, suggesting ostial occlusion was possible (Figure 1E). After extensive dialogue, we decided to proceed with the repositionable Lotus valve. If occlusion occurred, we would remove the Lotus valve. After placement, the final aortogram demonstrated a patent left main artery (LM) with brisk flow into the left sinus of Valsalva (LSV) so we deployed the Lotus valve (Figures 1F and 1G, Online Video 1). She was discharged with dual antiplatelet therapy rather than anticoagulation given her increased risk of bleeding. Four months later she developed a myocardial infarction. Coronary angiography revealed a 95% LM narrowing from the native left aortic valve leaflet (LAVL) with likely secondary thrombus formation from slow flow in the now small LSV (Figures 1H and 1I, Online Video 2).
She was initiated on extracorporeal membrane oxygenation as a precaution followed by successful LM percutaneous coronary intervention. Passing wires through the compressed valve struts was difficult. Rather than snorkeling, we directly passed wires across the struts over a 2-wire system to provide the best support for percutaneous coronary intervention without disrupting the Lotus valve architecture (Figure 2). After angioplasty, the narrowing remained suggesting some mechanical obstruction by the LAVL. A 3.0 mm × 12 mm XIENCE stent (Abbott Vascular, Santa Clara, California) was then deployed to the LM ostium and post-dilated to 4.0 mm with no residual stenosis (Figure 1J, Online Videos 3 and 4). Four-dimensional computed tomography confirmed normal TAVR valve function without leaflet thrombosis. At her 2-month follow up she was back to her active lifestyle.
We postulate there was progressive obstruction of the LM from the LAVL, worsened by effacement of the LSV over time with resultant stasis and acute thrombus. Caution should be used when placing the Lotus valve unless the coronary heights and aortic sinuses are sufficient to completely prevent the leaflets from obstructing the ostia, which can worsen with effacement over time. The post-TAVR aortogram therefore should not provide false reassurance, and delayed ostial narrowing can occur. Additionally, the closely woven strut architecture of the Lotus valve, rather than open cells of other devices, might have made this complication worse and certainly made intervention very challenging.
In retrospect, our intensions with the repositionable Lotus valve were well founded. The patient was not considered an operative candidate; therefore, a valve that could be completely deployed and assessed before release was the only option.
Dr. Southard was a part of and enrolled patients into the REPRISE III trial; has received research support from Edwards Lifesciences, Boston Scientific, and Abbott/St. Jude Medical; and has received speaker fees from Edwards Lifesciences and Abbott/St. Jude Medical. Dr. Low has served on the advisory committee for Boston Scientific; and as a consultant for Abbott Vascular and Boston Scientific. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received October 30, 2017.
- Revision received December 6, 2017.
- Accepted January 2, 2018.
- 2018 American College of Cardiology Foundation