Extramural Compression of Anomalous Left Circumflex Artery During Bicuspid Transcatheter Aortic Valve Replacement
Presenter
Afif Hossain, MD, Rutgers New Jersey Medical School, Paramus, NJ
Perry Wengrofsky, MD1, Afif Hossain, MD2, Liam Flanagan3, Krittika Pant3, Saeed Tarabichi4, Arash Salemi, MD, FACS5, Louis Stein4 and Bruce J. Haik, MD, FSCAI6, (1)SUNY Downstate Medical Center, Brooklyn, NY, (2)Rutgers New Jersey Medical School, Paramus, NJ, (3)Rutgers New Jersey Medical School, Newark, NJ, (4)Cooperman Barnabas Medical Center, Livingston, NJ, (5)Newark Beth Israel Medical Center, Newark, NJ, (6)Saint Barnabas Medical Center, Bedminster, NJ
Title
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Extramural Compression of Anomalous Left Circumflex Artery During Bicuspid Transcatheter Aortic Valve Replacement
Introduction
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As transcatheter aortic valve replacement (TAVR) continues to evolve, both procedurally and among patients with varying degrees of surgical risk and anatomical complexity, understanding the mechanisms of potential complications is essential. Among these are coronary artery occlusion by native valve leaflet material displacement, either covering the coronary ostia or walling off the sinus of Valsalva at the sinotubular junction. Aortic stenosis in the setting of a bicuspid aortic valve, the most common congenital heart disease occurring in 1-2% of the population and now representing 10% of TAVR patients, poses specific procedural considerations given variations of aortic root and coronary artery anatomy.
Clinical Case
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A 64-year-old woman with severe calcific bicuspid aortic stenosis was referred for TAVR. Pre-procedural transthoracic echocardiography (TTE) revealed a severely calcified bicuspid aortic valve (Figure A) and peak aortic velocity and mean aortic gradient of 4.7 m/s and 57 mm Hg, respectively. Cardiac computed tomography angiography (CCTA) identified an occult anomalous left circumflex artery (LCx) originating from the right coronary artery with intramural course along posterior aortic annulus (Figure B). Her case was reviewed by a multidisciplinary valve team, and TAVR was planned after discussion and consideration of surgical alternatives, co-morbidities, and multiple patient factors portending a hostile aortic root and higher risk of coronary obstruction, including small root, long leaflets, low coronary ostia heights, and valve calcium score > 4000 (Figure C/Slide 3 – Figure G/Slide 7). Pre-procedural invasive coronary angiography redemonstrated the anomalous LCx without any evidence of obstructive coronary artery disease (Video 1/Slide 8). Given heavy valvular calcification, pre-dilation balloon aortic valvuloplasty was performed with a 23 mm ZMed balloon (B. Braun Interventional Systems Inc., Bethlehem, Pennsylvania, USA) during rapid ventricular pacing at 170 beats per minute. Simultaneous supra-valvular aortography was performed during inflation to aid in valve sizing. During injection, clear compression of the proximal portion of the LCx was seen from calcium shifting towards the annulus, accompanied by hypotension and lateral ST-segment elevation (Video 2/Slide 9). The compression, blood pressure, and ST-segment elevation immediately improved after deflation, with repeat coronary angiography demonstrating a fully patent and recoiled LCx (Video 3/Slide 10). The TAVR procedure was aborted, and she was subsequently referred for surgical aortic valve replacement.
Discussion
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While there are limited prior reports describing anomalous coronary artery narrowing or obstruction during TAVR, this was the first case of a transcatheter heart valve affecting a coronary artery with anomalous origin in calcific bicuspid aortic stenosis. TAVR in the setting of coronary arteries of anomalous origin, which commonly accompany bicuspid aortic valves, requires comprehensive assessment of potential dynamic obstruction from calcified leaflets, both intramural coronary ostia, as well extramural compression of anomalous coronary arteries.