Thromboembolic Occlusion of the Left Coronary Artery During Transcatheter Aortic Valve Implantation

J INVASIVE CARDIOL 2018;30(2):E21-E22.

Key words: cardiac imaging, TAVI, occlusion

A 62-year-old female who presented with severe, symptomatic aortic stenosis was scheduled for transcatheter aortic valve implantation (TAVI) considering her class III obesity (body mass index, 42 kg/m²). The patient was chronically receiving only 75 mg of aspirin daily at the moment of TAVI and a loading dose of clopidogrel was planned by the end of the procedure. Intravenous heparin was administered at a dose of 10,000 U and an activated clotting time of 360 sec was achieved. During direct deployment of a 27 mm Portico bioprosthesis (St. Jude Medical) with no predilation, the patient gradually developed hypotension with systolic blood pressure drop and bradycardia. The unselective injection into the aortic root revealed presence of possible thrombus formation in proximal segments of the left anterior descending (LAD) and left circumflex (LCX) coronary arteries (Figure 1A). However, the decision was made to continue with the deployment of the bioprosthesis considering its correct positioning. Immediately after full deployment, cardiac arrest occurred. Afterward, a 6 Fr Extra Backup 3.5 catheter was inserted into the left coronary artery (LCA) through the aortic bioprosthesis frame struts (Figure 1B). Selective visualization confirmed thrombus within proximal segments of the LCX and LAD. Standard thrombus aspiration within the LCX was successfully performed. Intravenous infusion of abciximab was also administered. Control contrast injection into the LCA showed remaining thrombus (Figure 1C); thus, a second aspiration was attempted, which resulted in restoration of normal TIMI 3 flow (Figure 1D). Final aortography showed proper valve positioning and no paravalvular leak (Figure 1E). Thrombus evacuated during the second aspiration is shown in Figure 1F. Subsequent transthoracic echocardiography with visualization of the left ventricle confirmed preservation of systolic function and the patient was discharged after 7 days. 

Interventional management of adverse events within coronary arteries in patients with previously implanted transcatheter heart valve is particularly demanding due to frame struts or commissures restricting access to the coronary ostium. We believe the large-cell geometric design of the Portico bioprosthesis allowed efficient crossing of the coronary ostium with a guiding catheter – proving percutaneous coronary intervention to be feasible in an emergency environment.

References

1.    Eggebrecht H, Schmermund A, Voigtlander T, Kahlert P, Erbel R, Mehta RH. Risk of stroke after transcatheter aortic valve implantation (TAVI): a meta-analysis of 10,037 published patients. EuroIntervention. 2012;8:129-138. 

2.    Allali A, El-Mawardy M, Schwarz B, et al. Incidence, feasibility and outcome of percutaneous coronary intervention after transcatheter aortic valve implantation with a self-expanding prosthesis. Results from a single center experience. Cardiovasc Revasc Med. 2016;17:391-398.

From the First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Huczek reports proctor and speaker fees from Medtronic. The remaining authors report no conflicts of interest regarding the content herein.

Manuscript accepted June 2, 2017. 

Address for correspondence: Piotr Scislo, MD, PD, I Chair and Department of Cardiology, Medical University of Warsaw, Banacha 1a St., 02-097 Warsaw, Poland. Email: piotr.scislo@gmail.com