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Upper-extremity Approach for Secondary Access in Transfemoral Transcatheter Aortic Valve Implantation
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When we should say no to TAVR-Defining the line between utility and futility

Zubair A Khan1, Janah Aji1, Armaghan Soomro2

  • 1Cooper University Hospital, Camden, NJ 08109, USA.

Cardiovascular Revascularization Medicine : Including Molecular Interventions
|July 12, 2016
PubMed

Insights

Patients with prior coronary artery bypass surgery (CABG) undergoing transcatheter aortic valve replacement (TAVR) face increased risks. This case highlights avoiding transapical TAVR to prevent injury to epicardial collateral circulation.

Area of Science:

  • Cardiology
  • Interventional Cardiology
  • Cardiac Surgery

Background:

  • Prior coronary artery bypass surgery (CABG) is common in severe symptomatic aortic stenosis (AS) patients unsuitable for traditional surgery.
  • These patients exhibit higher peri-operative risks compared to those without prior CABG.
  • Concomitant peripheral arterial disease (PAD) and patent left internal mammary artery (LIMA) grafts complicate TAVR access.

Observation:

  • An 84-year-old female with prior CABG and severe PAD presented with severe symptomatic AS.
  • She underwent transapical TAVR, resulting in acute myocardial injury due to damage to apical epicardial collateral circulation.
  • This complication underscores the vulnerability of coronary collateral vessels during transapical procedures.

Findings:

  • The case demonstrates a rare complication of transapical TAVR in a patient with extensive prior CABG and PAD.
  • Damage to epicardial collateral circulation led to acute myocardial injury.
  • Recognition of coronary collateralization is crucial for procedural planning and patient safety.

Implications:

  • Transapical TAVR may need to be avoided in patients with prior CABG and compromised coronary collateralization.
  • Peri-procedural angiographic or fluoroscopic guidance is essential to prevent inadvertent injury to epicardial vessels.
  • Careful patient selection and procedural technique are paramount to minimize risks in complex TAVR cases.

Keywords:
ComplicationsCoronary collateralsMyocardial infarctionTranscatheter aortic valve replacement

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