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Published on: August 16, 2021
[High-risk percutaneous coronary intervention using hemodynamic support device eight years after transcatheter aortic
Carolina Montonati1, Luca Nai Fovino1, Tommaso Fabris1
1Dipartimento di Scienze Cardio-Toraco-Vascolari e Sanità Pubblica, Università degli Studi, Padova.
Insights
Ensuring coronary access after trans-catheter aortic valve implantation (TAVI) is crucial, especially with repeat procedures. Low-frame TAVI prostheses facilitate coronary access, even after a TAVI-in-TAVI, improving patient outcomes.
Area of Science:
- Cardiology
- Interventional Cardiology
- Bioprosthetic Heart Valves
Background:
- Coronary artery disease is common in severe aortic stenosis patients undergoing trans-catheter aortic valve implantation (TAVI).
- Ensuring coronary access post-TAVI is critical, particularly as indications expand to younger, lower-risk patients.
- Increased life expectancy post-TAVI may lead to a higher incidence of TAVI-in-TAVI procedures due to valve degeneration.
Observation:
- A patient with coronary artery disease and severe aortic stenosis, treated with TAVI, presented with acute coronary syndrome 8 years post-procedure.
- The patient had a low-frame transcatheter heart valve implanted during the initial TAVI.
- This allowed for successful coronary angiography and high-risk percutaneous coronary intervention with hemodynamic support.
Findings:
- The low frame height of the transcatheter aortic valve facilitated easy coronary access.
- This enabled a complex percutaneous coronary intervention despite the prior TAVI procedure.
- The case demonstrates the feasibility of coronary access even in the context of potential future TAVI-in-TAVI.
Implications:
- Implantation of low-frame transcatheter valves is vital for maintaining coronary access in TAVI patients.
- This strategy enhances the feasibility of future interventions, including TAVI-in-TAVI.
- Choosing low-profile devices can prevent patients from facing the paradox of needing surgery when older and frailer.
Abstract:
Coronary artery disease is a frequent comorbidity in patients with severe aortic stenosis undergoing trans-catheter aortic valve implantation (TAVI) and the need to ensure coronary access after TAVI is fundamental. This aspect is becoming increasingly relevant as TAVI indication expand to younger and lower-risk patients. Moreover, the longer life expectancy of subjects who are currently treated with TAVI could result in an increased need for TAVI-in-TAVI due to valve degeneration. As the implantation of a second transcatheter bioprosthesis might impair coronary access, TAVI-in-TAVI will be unfeasible in a significant proportion of cases, particularly if they received a tall-frame transcatheter heart valve at the time of the first intervention. Thus, patients might experience the paradox of needing surgical aortic valve replacement when they are older and frailer. Here we report the case of a patient with history of coronary artery disease and severe aortic stenosis treated with TAVI, presenting with an acute coronary syndrome 8 years after percutaneous aortic valve implantation. Thanks to the low frame height of the transcatheter aortic valve, it was possible to easily perform coronary angiography and high-risk percutaneous coronary intervention using hemodynamic support device (Impella CP). Moreover, this case highlights how the implantation of a low-frame transcatheter prosthesis can increase the possibility of achieving coronary access even after TAVI-in-TAVI, if needed.
