Scientific letter
Guidewire protection for a valve-in-valve transcatheter aortic valve implantation procedure with high-risk for coronary obstruction
Protección coronaria con guía para un procedimiento de alto riesgo de obstrucción coronaria tras implantación de válvula aórtica transcatéter
Ricardo Allende, Henrique Barbosa Ribeiro, Jean-Michel Paradis, Daniel Doyle, Sergio Pasian, Josep Rodés-Cabau
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josep.rodes@criucpq.ulaval.ca
Corresponding author at: Quebec Heart & Lung Institute, Laval University, 2725 Chemin Sainte-Foy, G1V 4G5 Quebec, QC, Canada.
Corresponding author at: Quebec Heart & Lung Institute, Laval University, 2725 Chemin Sainte-Foy, G1V 4G5 Quebec, QC, Canada.
Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
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Measurements of the sinus of Valsalva were obtained from the mean of the maximum and minimum cross-sectional diameters in the short-axis view (C).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Transcatheter aortic valve implantation (TAVI) has emerged as an effective option for the treatment of high-risk patients with native aortic stenosis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Furthermore, there has been a rapid expansion of TAVI toward a larger spectrum of patients, such as those with degenerative surgical bioprosthesis.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> While the procedure is successful in most cases, some life-threatening complications such as coronary obstruction still remain.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> Anatomical factors such as low lying coronary ostia and shallow sinus of Valsalva have been associated with a higher risk for coronary obstruction,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> but no specific preventive measure has been established to date for this life-threatening complication. To this effect, we describe the case of a patient considered at high surgical risk for conventional aortic valve replacement in whom TAVI was carried-out. Due to high-risk features for coronary obstruction we decided to protect the left main coronary artery with a coronary guidewire prior to valve implantation.</p><p id="par0010" class="elsevierStylePara elsevierViewall">An 80-year-old frail male presented to the ER with rapidly progressive dyspnea (NYHA class III–IV) and chest-pain. He had surgical aortic valve replacement with a 23-mm Freestyle stentless bioprosthetic valve performed 14 years earlier with concomitant coronary artery bypass graft (CABG). An echocardiogram showed a mild stenosis of the bioprosthesis (peak gradient: 35<span class="elsevierStyleHsp" style=""></span>mmHg; mean gradient: 15<span class="elsevierStyleHsp" style=""></span>mmHg; aortic valve area: 0.96<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>), severe regurgitation due to leaflet rupture and reduced left ventricular ejection fraction (currently 35 vs. 50% 6 months earlier). A coronary angiography showed a severe lesion in the proximal left anterior descending artery (LAD). Due to the high-risk profile of the patient (logistic EuroSCORE: 20%; STS-PROM: 10%), the Heart Team opted for TAVI treatment, and the treatment of the LAD stenosis with a drug-eluting stent was successfully performed before the TAVI procedure. Angiographic computed tomography prior to TAVI showed a sinus of Valsalva diameter of 28<span class="elsevierStyleHsp" style=""></span>mm and height of the RCA and left main (LM) of 10 and 8<span class="elsevierStyleHsp" style=""></span>mm, respectively (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Taking into consideration these high-risk anatomical characteristics and the presence of a previous stentless bioprosthesis, we decided to perform the TAVI with left main guidewire protection.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The TAVI procedure was performed through transfemoral approach, under general anesthesia, with fluoroscopy and echocardiographic guidance. Before any maneuver at the level of the aortic valve, an extra-support Wiggle guidewire (Abbott Vascular, Santa Clara, CA, USA) was placed in the distal LAD (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The deployment of a 23-mm SAPIEN XT valve (Edwards Lifesciences Inc., Irvine, CA, USA) valve was performed under rapid pacing with the slow inflation technique,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and with the valve slightly more ventricular (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Immediately after valve deployment the patient presented ST-segment elevation and severe persistent hypotension. Using a DOC extension to the Wiggle guidewire, an Extra BackUP 6Fr guiding catheter was advanced and the contrast injection showed obstruction of the LM ostium (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). A pre-dilatation with a 4.0<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>mm balloon (Sprinter Legend RX-Medtronic, Minneapolis, MN, USA) restored the coronary flow and pressures, followed by a Promus Element stent (Boston Scientific, Natick, MA, USA) 4.0<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>mm implantation in the LM, partially protruding into the aorta. A final angiogram showed (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) no significant residual coronary stenosis and coronary flow TIMI 3. Following the procedure, the patient had an excellent recovery and was discharged four days later. At 6-month follow-up the patient was in NYHA class I, with a normofunctioning valve (mean gradient 20<span class="elsevierStyleHsp" style=""></span>mmHg, valve area of 1.1<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>, and mild paravalvular leak), and left ventricle ejection fraction of 55%. Cardiac CT demonstrated the permeability of the coronary stent with a good position of the SAPIEN XT valve.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Coronary obstruction following TAVI presents a high mortality rate (∼50%),<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> and is usually caused by the displacement of an aortic valve leaflet toward the coronary ostium, with an incidence of up to 3.5% in the context of TAVI in patients with prior surgical bioprosthesis (“valve-in-valve” – ViV-TAVI).<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The presence of low-lying coronary ostia and shallow sinus of Valsalva were identified as potential risk factors for this complication in our case.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The cutoffs determined by computed tomography, as of increased risk, are a LM height<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>mm and a sinus of Valsalva less<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>mm.<span class="elsevierStyleSup">4</span> Severe persistent hypotension, which is present in ∼70% of patients, and ST-segment changes immediately post-TAVI may establish the diagnosis in some cases.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> It has been shown that either crossing the obstruction with the guidewire and/or advancing a stent through the guidewire may be challenging in such cases.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> It has been therefore suggested that leaving a preventive stent in the coronary, together with the guidewire, might potentially avoid the difficulty in crossing with the stent throughout the valve stent frame.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion, coronary obstruction following TAVI, although rare, is a potential fatal complication. Some clinical and anatomical characteristics may determine a higher risk for its occurrence. In such patients, the preventive placement of a coronary guidewire may be advisable to promptly depict this complication and proceed with percutaneous coronary intervention. Future studies, with a larger number of patients at risk may confirm if this maneuver should be more widely recommended for patients undergoing TAVI with high-risk features for this complication.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0035" class="elsevierStylePara elsevierViewall">H.B.R. is supported by a research PhD grant from “<span class="elsevierStyleGrantSponsor" id="gs1">CNPq, Conselho Nacional de Desenvolvimento Científico e Tecnológico – Brasil</span> (246860/2012-0)”. The other authors declare not receiving any funding for this study.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">Dr. Josep Rodés-Cabau is a consultant for Edwards Lifesciences and St-Jude Medical. The rest of the authors have no conflict of interest to disclose.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 657 "Ancho" => 2500 "Tamanyo" => 144004 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Multi-detector computed tomography (MDCT) evaluation pre-TAVI showing the measurements in the long-axis view with a height of 10<span class="elsevierStyleHsp" style=""></span>mm for the right coronary artery (A) and 8.06<span class="elsevierStyleHsp" style=""></span>mm for the left coronary artery (B). Measurements of the sinus of Valsalva were obtained from the mean of the maximum and minimum cross-sectional diameters in the short-axis view (C).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 991 "Ancho" => 1500 "Tamanyo" => 147203 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Left coronary artery (LCA) angiography before deployment of the transcatheter valve (A). LCA protection with an extra-support Wiggle guidewire™ (B). Image showing the deployment of the transcatheter valve (C). Angiography showing partial ostial obstruction of the LCA after the transcatheter valve implantation (D). Pre-dilatation of the left main coronary artery with a 4.0<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>mm balloon (E). Final angiography after the successful deployment of a drug-eluting stent into the ostium of the left main coronary artery (F).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Transcatheter aortic valve implantation: current and future approaches" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J. 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Urena" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jcin.2012.11.014" "Revista" => array:6 [ "tituloSerie" => "JACC Cardiovasc Interv" "fecha" => "2013" "volumen" => "6" "paginaInicial" => "452" "paginaFinal" => "461" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23602458" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Predictive factors, management, and clinical outcomes of coronary obstruction following transcatheter aortic valve implantation: insights from a large multicenter registry" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "H.B. Ribeiro" 1 => "J.G. Webb" 2 => "R.R. Makkar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2013.07.040" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2013" "volumen" => "62" "paginaInicial" => "1552" "paginaFinal" => "1562" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23954337" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Transcatheter aortic valve implantation using the slow balloon inflation technique: making balloon-expandable valves partially repositionable" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M. Mok" 1 => "E. Dumont" 2 => "D. Doyle" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Card Surg" "fecha" => "2012" "volumen" => "27" "paginaInicial" => "546" "paginaFinal" => "548" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pre-emptive positioning of a coronary stent in the left anterior descending artery for left main protection: a prerequisite for transcatheter aortic valve-in-valve implantation for failing stentless bioprostheses? Catheterization and cardiovascular interventions" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "T. Chakravarty" 1 => "H. Jilaihawi" 2 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 0 | 5 |
| 2024 October | 20 | 5 | 25 |
| 2024 September | 6 | 7 | 13 |
| 2024 August | 11 | 8 | 19 |
| 2024 July | 13 | 5 | 18 |
| 2024 June | 10 | 2 | 12 |
| 2024 May | 5 | 5 | 10 |
| 2024 April | 19 | 4 | 23 |
| 2024 March | 23 | 1 | 24 |
| 2024 February | 29 | 3 | 32 |
| 2024 January | 29 | 3 | 32 |
| 2023 December | 36 | 9 | 45 |
| 2023 November | 42 | 9 | 51 |
| 2023 October | 51 | 10 | 61 |
| 2023 September | 26 | 2 | 28 |
| 2023 August | 21 | 4 | 25 |
| 2023 July | 56 | 2 | 58 |
| 2023 June | 46 | 6 | 52 |
| 2023 May | 64 | 8 | 72 |
| 2023 April | 34 | 0 | 34 |
| 2023 March | 43 | 6 | 49 |
| 2023 February | 40 | 4 | 44 |
| 2023 January | 54 | 9 | 63 |
| 2022 December | 45 | 3 | 48 |
| 2022 November | 52 | 9 | 61 |
| 2022 October | 61 | 12 | 73 |
| 2022 September | 38 | 20 | 58 |
| 2022 August | 49 | 19 | 68 |
| 2022 July | 33 | 9 | 42 |
| 2022 June | 16 | 6 | 22 |
| 2022 May | 19 | 5 | 24 |
| 2022 April | 24 | 5 | 29 |
| 2022 March | 43 | 10 | 53 |
| 2022 February | 53 | 4 | 57 |
| 2022 January | 67 | 9 | 76 |
| 2021 December | 43 | 16 | 59 |
| 2021 November | 31 | 15 | 46 |
| 2021 October | 37 | 11 | 48 |
| 2021 September | 45 | 8 | 53 |
| 2021 August | 58 | 11 | 69 |
| 2021 July | 47 | 15 | 62 |
| 2021 June | 48 | 6 | 54 |
| 2021 May | 40 | 10 | 50 |
| 2021 April | 105 | 19 | 124 |
| 2021 March | 39 | 8 | 47 |
| 2021 February | 56 | 6 | 62 |
| 2021 January | 41 | 13 | 54 |
| 2020 December | 47 | 4 | 51 |
| 2020 November | 22 | 7 | 29 |
| 2020 October | 18 | 6 | 24 |
| 2020 September | 24 | 7 | 31 |
| 2020 August | 15 | 6 | 21 |
| 2020 July | 26 | 2 | 28 |
| 2020 June | 21 | 7 | 28 |
| 2020 May | 19 | 8 | 27 |
| 2020 April | 19 | 5 | 24 |
| 2020 March | 20 | 9 | 29 |
| 2020 February | 18 | 8 | 26 |
| 2020 January | 28 | 3 | 31 |
| 2019 December | 62 | 5 | 67 |
| 2019 November | 45 | 1 | 46 |
| 2019 October | 24 | 2 | 26 |
| 2019 September | 37 | 10 | 47 |
| 2019 August | 13 | 5 | 18 |
| 2019 July | 31 | 19 | 50 |
| 2019 June | 83 | 7 | 90 |
| 2019 May | 180 | 17 | 197 |
| 2019 April | 83 | 16 | 99 |
| 2019 March | 17 | 6 | 23 |
| 2019 February | 17 | 13 | 30 |
| 2019 January | 14 | 8 | 22 |
| 2018 December | 17 | 18 | 35 |
| 2018 November | 25 | 10 | 35 |
| 2018 October | 33 | 14 | 47 |
| 2018 September | 9 | 5 | 14 |
| 2018 August | 14 | 12 | 26 |
| 2018 July | 8 | 10 | 18 |
| 2018 June | 10 | 4 | 14 |
| 2018 May | 3 | 2 | 5 |
| 2018 April | 21 | 3 | 24 |
| 2018 March | 17 | 4 | 21 |
| 2018 February | 10 | 3 | 13 |
| 2018 January | 14 | 1 | 15 |
| 2017 December | 17 | 2 | 19 |
| 2017 November | 13 | 7 | 20 |
| 2017 October | 18 | 9 | 27 |
| 2017 September | 8 | 18 | 26 |
| 2017 August | 16 | 16 | 32 |
| 2017 July | 16 | 4 | 20 |
| 2017 June | 20 | 17 | 37 |
| 2017 May | 42 | 20 | 62 |
| 2017 April | 23 | 22 | 45 |
| 2017 March | 57 | 95 | 152 |
| 2017 February | 46 | 9 | 55 |
| 2017 January | 28 | 7 | 35 |
| 2016 December | 28 | 20 | 48 |
| 2016 November | 44 | 9 | 53 |
| 2016 October | 58 | 12 | 70 |
| 2016 September | 68 | 9 | 77 |
| 2016 August | 36 | 9 | 45 |
| 2016 July | 38 | 3 | 41 |
| 2016 June | 28 | 7 | 35 |
| 2016 May | 46 | 17 | 63 |
| 2016 April | 42 | 18 | 60 |
| 2016 March | 37 | 18 | 55 |
| 2016 February | 37 | 30 | 67 |
| 2016 January | 33 | 21 | 54 |
| 2015 December | 39 | 20 | 59 |
| 2015 November | 24 | 20 | 44 |
| 2015 October | 42 | 22 | 64 |
| 2015 September | 28 | 20 | 48 |
| 2015 August | 15 | 4 | 19 |
| 2015 July | 27 | 7 | 34 |
| 2015 June | 18 | 6 | 24 |
| 2015 May | 29 | 10 | 39 |
| 2015 April | 62 | 25 | 87 |
| 2015 March | 38 | 20 | 58 |
| 2015 February | 61 | 34 | 95 |
| 2015 January | 54 | 40 | 94 |
| 2014 December | 37 | 13 | 50 |
Show all