Late Right Coronary Ostium Occlusion After Percutaneous Aortic Paravalvular Leak Closure: Immediate Results Do Not Always Predict Long-Term Performance

Abstract: We present an 83-year-old woman with history of two aortic valve replacements; 2 years after the last replacement, she developed heart failure and severe paravalvular leak  (PVL) was detected. Percutaneous PVL closure was completed with a single Amplatzer Vascular Plug III. Two months later, the patient presented with late coronary obstruction requiring emergent surgical revascularization. To the best of our knowledge, this is the first report of late coronary obstruction after percutaneous PVL closure.

J INVASIVE CARDIOL 2016;28(8):E69-E70

Key words: aortic paravalvular leak, complications, late device interference, coronary obstruction

Case Presentation

We present an 83-year-old woman with a history of two aortic valve replacements, the last with a 17 mm Slimline mechanical valve (Sorin). Two years after the last aortic valve replacement, she developed heart failure and a severe right paravalvular leak (PVL) was detected. Percutaneous PVL closure was scheduled. With a retrograde approach, a single 5 x 14 mm Amplatzer Vascular Plug III (St. Jude Medical) was implanted and major reduction of aortic regurgitation was observed. Despite the proximity of the device to the right coronary artery (RCA) ostium, coronary flow was assessed and confirmed in multiple projections before releasing the device. Anticoagulation with acenocoumarol was restarted and the patient was discharged. One month later, she was completely asymptomatic after clinical evaluation. Two months later, she presented with an inferior myocardial infarction. Angiography confirmed the partial obstruction of the RCA ostium with the device. The patient underwent emergent surgical revascularization with a saphenous vein graft to the distal RCA without further complications. 

Discussion

Percutaneous PVL closure has proven safety and efficacy, with reduction of cardiac mortality and functional class improvement.¹ Although infrequent, mechanical complications such as device embolization, disc interference, or coronary obstruction may occur.² Price et al described an acute left main impingement with an Amplatzer Vascular Plug II device.³ To the best of our knowledge, this is the first report of late coronary obstruction after percutaneous PVL closure. Since no device dislodgment was observed, late device endothelialization/thrombosis and subsequent flow interference was the most plausible explanation. Different percutaneous strategies such as device recapture (snare systems) or stent implantation to deflect the device have been proposed.³ In any case, operators should be aware of this complication and try to avoid any interference between the device and coronary arteries, even when coronary filling does not seem compromised in the acute setting.

References

1.     Millan X, Skaf S, Joseph L, et al. Transcatheter reduction of paravalvular leaks: a systematic review and meta-analysis. Can J Cardiol. 2015;31:260-269. 

2.    Rihal CS, Sorajja P, Booker JD, Hagler DJ, Cabalka AK. Principles of percutaneous paravalvular leak closure. JACC Cardiovasc Interv. 2012;5:121-130. 

3.    Price MJ, Shah MG, Burke RF, Riley RD, Rizik DG. Impingement of left main ostium after device occlusion of paravalvular leak post-transcatheter aortic valve replacement. JACC Cardiovasc Interv. 2015;8:e1-e2. 

From the ¹Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain; and ²Cardiovascular Surgery Department, Cardiovascular Institute (ICCV), Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Hernández-Enríquez is supported by a research grant from the Working Group on Interventional Cardiology of the Spanish Society of Cardiology. Dr Freixa is a proctor for St. Jude Medical. The remaining authors report no conflicts of interest regarding the content herein.

Manuscript submitted April 15, 2016, provisional acceptance given April 18, 2016, final version accepted April 22, 2016.

Address for correspondence: Marco Hernández-Enríquez, MD, Hospital Clínic, C/Villarroel, 170, Cardiology Department, 08036 Barcelona, Spain. Email: mhernane@clinic.ub.es