Keywords
1. Transcatheter aortic valve implantation (TAVI)
2. Ostial left main disease
3. Valve-in-valve procedure
4. Percutaneous coronary intervention
5. Cardiovascular revascularization
Introduction
In the ever-evolving world of interventional cardiology, transcatheter aortic valve implantation (TAVI) has become a cornerstone for the treatment of aortic stenosis (AS) in patients deemed at high surgical risk. Nonetheless, it is not without complications, one of the most challenging of which is the occurrence of subocclusive ostial left main coronary artery (LMCA) disease post-procedure. This article elucidates a groundbreaking case, as detailed by Dr. Arturo Giordano and colleagues in Cardiovascular Revascularization Medicine, highlighting the intricate bail-out valve-in-valve procedure which successfully addressed the critical complication (DOI: 10.1016/j.carrev.2019.04.003).
Background
Aortic stenosis is a condition characterized by the narrowing of the aortic valve, leading to obstructed blood flow from the heart. TAVI has revolutionized the management of AS by offering a minimally invasive option compared to the traditional open-heart surgery. While a life-saving alternative for many, especially the elderly or those unfit for surgery, TAVI procedures can sometimes be complicated by unforeseen obstructions in the coronary arteries, necessitating additional interventions.
Case Presentation
The report published in 2019 profiles a female aged patient with severe AS who underwent a TAVI procedure. Initial TAVI was successful; however, it was complicated by a subocclusive ostial LMCA lesion, posing a significant risk to the patient’s life. Such occurrences are rare but can result in catastrophic outcomes including myocardial infarction or death if not swiftly managed.
Management and Outcomes
The patient was treated with an urgent percutaneous coronary intervention (PCI), where a stent is used to open the blocked artery. However, due to the nature of the blockage at the ostial LMCA, coupled with the presence of the new aortic valve, the intervention was not straightforward. A valve-in-valve procedure was performed as a bail-out strategy, wherein a second TAVI valve was implanted within the existing prosthetic valve. This approach not only resolved the subocclusive lesion but also ensured the sustained functionality of the aortic valve.
Discussion
This case emphasizes the necessity of readiness for immediate coronary intervention post-TAVI. Prompt recognition of subocclusive ostial LMCA disease and appropriate use of the valve-in-valve technique can be life-saving, as demonstrated in this patient’s scenario. It also brings attention to the importance of a multidisciplinary heart team approach, where collaboration between cardiologists and cardiovascular surgeons is paramount for successful outcomes.
Conclusion
Subocclusive ostial LMCA disease is a rare but serious complication of TAVI. The multifaceted approach, encompassing immediate PCI and valve-in-valve strategy presents an effective solution for this critical problem. This case serves to inform interventional cardiologists of the potential challenges and required vigilance during and after TAVI procedures.
References
1. Giordano, A., Ferraro, P., Biondi-Zoccai, G., & Corcione, N. (2019). Subocclusive Ostial Left Main Disease After Transcatheter Aortic Implantation with Bail-Out Valve-in-Valve. Cardiovascular Revascularization Medicine: Including Molecular Interventions, 928-930. DOI:10.1016/j.carrev.2019.04.003. S1553-8389(19)30229-5.
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