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Delayed Coronary Obstruction After Transcatheter Aortic Valve Replacement
Richard J Jabbour1, Akihito Tanaka2, Ariel Finkelstein3
1Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy; Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy; Imperial College London, London, United Kingdom.
Insights
Delayed coronary obstruction (DCO) after transcatheter aortic valve replacement (TAVR) is rare but serious. This complication, occurring in 0.22% of TAVR cases, is linked to a high in-hospital mortality rate.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Delayed coronary obstruction (DCO) is an infrequent complication post-transcatheter aortic valve replacement (TAVR).
- Understanding the incidence and characteristics of DCO is crucial for patient management.
Purpose of the Study:
- To determine the incidence and pathophysiological features of DCO following TAVR.
- To analyze clinical presentation, management, and outcomes of DCO.
Main Methods:
- Retrospective analysis of data from an international multicenter registry (18 centers, Nov 2005-Dec 2016).
- Identification of DCO cases among 17,092 TAVR procedures.
- Review of procedural details, clinical presentation, interventions, and mortality.
Main Results:
- DCO occurred in 0.22% (38/17,092) of TAVR procedures.
- Higher incidence observed in valve-in-valve procedures and with self-expandable valves.
- Most frequent presentation was cardiac arrest (31.6%), with left main coronary artery obstruction in 92.1%.
- In-hospital mortality rate was 50%, significantly higher if DCO occurred within 7 days.
Conclusions:
- DCO post-TAVR is a rare but life-threatening complication.
- Early recognition and coronary angiography are essential for suspected cases.
- Awareness of DCO risk factors and timing is critical for TAVR clinicians.
Background:
Delayed coronary obstruction (DCO) is an uncommon and barely reported complication following transcatheter aortic valve replacement (TAVR).
Objectives:
The aim of this study was to describe the incidence and pathophysiological features of DCO after TAVR, obtained from a large international multicenter registry.
Methods:
Data were retrospectively collected from an international multicenter registry consisting of 18 centers between November 2005 and December 2016.
Results:
During the study period, 38 DCO (incidence 0.22%) cases were identified from a total of 17,092 TAVR procedures. DCO occurred more commonly after valve-in-valve procedures (0.89% vs. 0.18%; p < 0.001) and if self-expandable valves were used during the index procedure (0.36% vs. 0.11% balloon expandable; p < 0.01). DCO was most likely to occur ≤24 h after the TAVR procedure (47.4%; n = 18); 6 (15.8%) cases occurred between 24 h and ≤7 days, with the remaining 14 (36.8%) at ≥60 days. The most frequent presentation was cardiac arrest (31.6%; n = 12), followed by ST-segment elevation myocardial infarction (23.7%; n = 9). The left coronary artery was obstructed in most cases (92.1%; n = 35). Percutaneous coronary intervention was attempted in the majority of cases (74.3% left main; 60% right coronary), and stent implantation was successful in 68.8%. The overall in-hospital death rate was 50% (n = 19), and was higher if DCO occurred ≤7 days from the index procedure (62.5% vs. 28.6%; p = 0.09).
Conclusions:
DCO following TAVR is a rare phenomenon that is associated with a high in-hospital mortality rate. Clinicians should be aware that coronary obstruction can occur after the original TAVR procedure and have a low threshold for performing coronary angiography when clinically suspected.
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