Title:
An Ounce of Prevention Leads to a Pound of Trouble! A Case of coronary protection in valve-in-valve complicated by valve embolization.
Introduction:
Valve-in-Valve transcatheter aortic valve replacement (ViV) in patients with failed surgical valve bioprosthesis is an alternative and effective therapy in patients deemed to be at high or prohibitive risk for redo surgical aortic valve replacement. We are presenting a case of transcatheter aortic valve replacement due to severe bioprosthetic aortic valve insufficiency, complicated by valve embolization due to mal-positioned left main coronary artery stent, used for coronary protection.
Clinical Case:
A 78-year-old male patient with history of surgical aortic valve replacement (11 years before presentation with 27 mm- Freestyle stent-less bioprosthetic valve (Medtronic, Minneapolis, MN)), severe acute heart failure, recent history of endocarditis status post successful treatment, found to have severe aortic insufficiency. Patient was evaluated by heart team and deemed to be high surgical candidate. Therefore, he was considered for ViV as the ultimate treatment approach. During the procedure, the left main coronary artery was engaged and undeployed stent was positioned in mid-left anterior descending artery as patient noted to be at high risk of left main coronary artery obstruction due to short distance between the virtual valve-to-leaflet. A 29 mm- Edwards Sapien 3 Ultra valve (Edwards Lifesciences, Irvine, CA) was positioned inside the surgical valve and deployed. It was noted that the stent delivery system was stuck between the valve and the left main coronary artery. Multiple attempts to remove the stent and delivery system were made. However, this resulted in migration of the transcatheter aortic bioprosthesis into the aortic root. Another 29 mm- Edwards Sapien 3 Ultra valve was advanced and positioned across the aortic valve, overlapping with the first bioprosthetic valve. The valve was deployed, and trans-esophageal echocardiography showed good valve position and no central or perivalvular leak. Non-selective angiography showed patent left main coronary artery.
Discussion:
Coronary artery protection might be necessary and lifesaving in some TAVR cases. Chimney technique is safe and widely used. However, it is still associated with intra-procedural complications. Managing complications related to the technique is key to avoid undesirable, yet avoidable outcome.