Challenging Coronary Intervention Through Valve in Valve Self Expanding Bioprosthesis
Presenter
Chris S Abrahim, MD, Hackensack University Medical Center, Hackensack, NJ
Chris S Abrahim, MD1, Craig Basman, MD, FACC, FSCAI1, Kalpeshkumar K Shah, MD2, Paul Andrews, MD, FACC1, Vladmir Jelnin, MD1, Ryan Kaple, MD3, Pranaychandra Vaidya, M.D.1 and Haroon Faraz, M.D., FSCAI1, (1)Hackensack University Medical Center, Hackensack, NJ, (2)Hackensack University Medical Center, Wallington, NJ, (3)Hackensack University Medical Center, Brooklyn, NY
Title:
Fusion Imaging Guidance for Difficult Coronary Re-access in a Patient with Valve-in-Valve Transcatheter Aortic Valve Replacement
Introduction:
Coronary re-access can be difficult after transcatheter aortic valve replacement (TAVR). Valve-in-valve (ViV) TAVR may create further difficulties due to the neoskirt and transcatheter frame. In this case we present a technically challenging Left Main Intervention as a result of a ViV TAVR with a self-expandable transcatheter heart valve (THV) creating difficulty with coronary re-access, by which coronary access was facilitated by computed tomography (CT) -fluoroscopy fusion imaging.
Clinical Case:
An 84 year old man presented with unstable angina. He is known to have a history of a remote CABG and AVR (23mm Mosaic) and underwent ViV TAVR in 2017 with a 26mm Corevalve. He was taken for urgent cardiac catheterization and found to have a patent LIMA graft, but was unable to engage the left coronary system to perform selective angiography. Non-selective angiography revealed severe calcific disease of the distal left main and ostial circumflex artery. The patient was taken off the table and placed on anti-anginals and intravenous heparin. A multidisciplinary team meeting was held and patient underwent a Structural CT for interventional planning. The CT revealed a neo-skirt that extended to the sinotubular junction (STJ) with a small valve-to-STJ (VT-STJ) < 2mm that explained the difficulty with coronary re-access. The patient was brought back for staged PCI and planned to use CT-fluoroscopy fusion guidance to locate a point of re-entry in which there would be a plan for electrocautery to split the prior AVR leaflet creating the barrier for coronary re-acces. Using CT-fluoro fusion a 7Fr AL1 guiding was able to cross the ideal cell of the TAVR valve, which was determined a priori using CT planning, and deflect the surgical leaflet to facilitate access to the coronary ostium without the need for advanced electrocautery maneuvers. The coronary lesion was then able to be treated with intravascular lithotripsy with excellent result.
Discussion:
Coronary re-access may be difficult for a variety of reasons after ViV TAVR. Pre-procedural planning and utilization of intra-procedural fusion imaging may help improve success rates.