Author + information
- Received May 14, 2019
- Revision received July 8, 2019
- Accepted July 11, 2019
- Published online October 16, 2019.
- Frederic Bouisset, MDa,∗ (, )
- Bertrand Marcheix, MD, PhDb,
- Etienne Grunenwald, MDb and
- Thibault Lhermusier, MD, PhDa
- aDepartment of Cardiology, Rangueil University Hospital, Toulouse, France
- bDepartment of Cardiac Surgery, Rangueil University Hospital, Toulouse, France
- ↵∗Address for correspondence:
Dr. Frederic Bouisset, Department of Cardiology, Toulouse University Hospital, 1, avenue Jean Poulhès, TSA 50032, 31059 Toulouse Cedex 9, France.
We present a case of an 80-year-old woman with severe aortic insufficiency due to a degenerated 21-mm biological prosthetic aortic valve implanted 9 years earlier, treated by using a transcatheter aortic valve replacement valve-in-valve procedure and who experienced a delayed right coronary obstruction. (Level of Difficulty: Beginner.)
An 81-year-old woman with a 21-mm Mitroflow bioprosthetic aortic valve (Sorin Group, Milan, Italy) replacement 9 years earlier was referred for a severe symptomatic aortic regurgitation due to bioprosthesis dysfunction. The heart team planned a transcatheter aortic valve replacement valve-in-valve (ViV) procedure. A 23-mm CoreValve Evolut R prosthesis (Medtronic, Minneapolis, Minnesota) was implanted via the right transfemoral route with good immediate result (Figure 1A).
The patient presented a cardiogenic shock 24 h later, with no chest pain or ST-segment changes on electrocardiogram but a severe biventricular dysfunction on transthoracic echocardiography (TTE). Emergency cardiac catheterization revealed a right dominant coronary artery occlusion (Figure 1B). This artery was reopened by percutaneous coronary intervention, and a 4.0-mm Resolute Onyx drug-eluting stent (Medtronic) was successfully implanted through the transcatheter heart valve into the artery (Figure 1C).
The patient recovered progressively. At day 7, TTE revealed normal ventricular functions with a 10 mm Hg mean gradient in the aortic ViV. Multislice computed tomography imaging showed a good patency of the left and right coronaries (Figure 1D). At 12 months, the patient remains asymptomatic with stable TTE parameters.
Coronary obstruction is a dramatic complication after transcatheter aortic valve replacement and is more frequent following the ViV procedure (1), with an incidence of 2.3% in the VIVID (Valve-in-Valve International Data) registry (2). This complication mostly involves the left coronary artery and occurs within minutes after implantation, but it can also occur a few hours to several months later, with a poor prognosis (3).
In the current case, 2 major parameters led to this complication. The first was the presence of a Mitroflow valve with leaflets mounted externally of the stent (2). The second factor was the tight aortic root anatomy with a short virtual transcatheter valve to coronary ostium distance (Figure 1E), the most powerful predictive factor for coronary occlusion after ViV procedure, with an optimal cutoff level of 4 mm (2) and a short annulus–coronary ostia distance (Figure 1F).
Dr. Marcheix is a proctor for Edwards Lifesciences and Medtronic. Dr. Lhermusier has received speaker and consulting fees from Abbott, Boston Scientific, Medtronic, and Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Abbreviations and Acronyms
- transthoracic echocardiography
- Received May 14, 2019.
- Revision received July 8, 2019.
- Accepted July 11, 2019.
- 2019 The Authors
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- Ribeiro H.B.,
- Rodes-Cabau J.,
- Blanke P.,
- et al.
- Jabbour R.J.,
- Tanaka A.,
- Finkelstein A.,
- et al.