Author + information
- Received April 12, 2017
- Revision received May 22, 2017
- Accepted June 20, 2017
- Published online October 16, 2017.
- Marco Spaziano, MDa,
- Mariama Akodad, MDa,∗ (, )
- Thomas Hovasse, MDa,
- Thierry Lefèvre, MDa,
- Erik Bouvier, MDb and
- Bernard Chevalier, MDa
- aInterventional Cardiology Department, Ramsay Générale de Santé, Institut Cardiovasculaire Paris Sud, Massy, France
- bDepartment of Cardiology, Ramsay Générale de Santé, Institut Cardiovasculaire Paris Sud, Massy, France
- ↵∗Address for correspondence:
Dr. Mariama Akodad, Interventional Cardiology, Institut Cardiovasculaire Paris Sud, 6 Avenue du Noyer Lambert, 91100 Massy, France.
An 82-year-old woman was referred for transcatheter aortic valve replacement (TAVR) following hospitalizations for heart failure due to severe aortic stenosis. She was deemed inoperable by the heart team because of her age and her limited mobility due to multiple sclerosis. Pre-procedural computed tomography scan revealed a bicuspid aortic valve (type 1 with N-L [noncoronary–left coronary cusp] raphe), dilated aortic root, and anomalous origin of the left main coronary artery (LM) adjacent to the raphe, 4 mm above the annulus (Figures 1A to 1C).
Given the high risk of obstruction, the LM was wired from the radial approach, and a 3.5 × 38-mm Xience everolimus-eluting stent (Abbott Vascular, Santa Clara, California) was positioned beyond the ostium (Figure 1D). After pre-dilatation, a 29-mm Evolut-R valve (CoreValve EvolutR, Medtronic, Dublin, Ireland) was partially deployed. An aortogram showed severe pinching of the ostial LM and slow flow in the left anterior coronary artery (LAD) (Figure 1E). The stent was pulled back to position the distal marker just proximal to the LM bifurcation carina and deployed (Figure 1F). The valve was then released, but appeared constrained (Figure 1G). In order not to crush the “chimney stent” during valve post-dilatation, a “kissing” was performed with simultaneous inflation of the stent balloon and a 20-mm Edwards balloon selected according to the intercommissural distance (Figure 1H, Online Video 1). Final showed normal valve function and LM patency. We selected a 38-mm stent to have optimal LM coverage and to have the proximal part of the stent above the leaflets of the prosthesis, to ensure LM patency. Post-procedural computed tomography revealed good stent patency and little interaction between stent and valve (Figure 1I, Online Video 2).
TAVR is challenging in patients with low coronaries because of the risk of obstruction (1,2). The usefulness of LM protection has been demonstrated in a small series (3). This is the first report to our knowledge of “chimney” stenting of the LM followed by kissing post-dilatation during TAVR. This can be a useful strategy for patients with nonstenotic, but low, coronaries.
Dr. Akodad has received research grants from Edwards Lifesciences and Medtronic. Dr. Lefèvre has been a proctor for Edwards Lifesciences and Abbott Vascular. Dr. Chevalier has been a proctor for Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. The first 2 authors contributed equally to this work.
- Received April 12, 2017.
- Revision received May 22, 2017.
- Accepted June 20, 2017.
- 2017 American College of Cardiology Foundation
- Ribeiro H.B.,
- Nombela-Franco L.,
- Urena M.,
- et al.
- Ribeiro H.B.,
- Webb J.G.,
- Makkar R.R.,
- et al.