Cardiology Fellow Rochester Hills, Michigan, United States
Disclosure(s):
Michael M. Kattula, DO: No financial relationships to disclose
Background: Acute Coronary Obstruction (CO) following valve-in-valve procedures is a rare, but dreaded, complication with an occurrence rate of 2.5% and a mortality rate of 41%. Known risk factors include older age, female Sex, VTC distance < 4 mm, and a VTSTJ distance < 2 mm.
Methods: A 71-year-old female with a past medical history of surgical Aortic Valve Replacement with 21 mm Freedom Solo Valve 6 years prior to presentation, hypertension, hyperlipidemia. Her symptoms on presentation to the clinic included shortness of breath on minimal exertion consistent with NYHA Class III and chest pain with exertion. Transthoracic echocardiogram demonstrated a mean aortic valve gradient of 28 that increased to 52 mmHg with 10 mcg of dobutamine. Aortic Valve Area calculated at 0.23 cm2. She underwent a transesophageal (TEE) that demonstrated the following: A resting aortic valve gradient of 42 mmHg, aortic valve area by planimetry was 0.638 cm2, and moderate aortic regurgitation. She was turned down by CTS because she was felt to be a high risk Re-do, so she was scheduled for an elective valve-in-valve TAVR. Pertinent pre-procedural CT measurements included a VTC of 2.1-3.9 mm, and an STJ to LCA of 16.3 mm.
Outcome: The case was performed with a bilateral femoral arterial access approach. There was successful deployment of a 23 mm Edward Life Science Sapien 3 valve. The patient immediately became hypotensive following valve deployment. A non-selective angiogram with the pigtail still in place was concerning for complete occlusion of the left main coronary artery. An Ebu 3.5 guiding catheter was then inserted, and selective angiograms confirmed the suspicion of complete occlusion of the left main coronary artery secondary to valve obstruction. The patient remained hypotensive and went into ventricular fibrillation requiring 30-40 minutes of CPR and defibrillations. An Impella CP was placed for cardiogenic shock with refractory cardiac arrest. A wire was passed through the LAD and Left Circumflex arteries with multiple balloon inflations that restored flow down the left coronary system. A 4.0 x 12 mm Stent was subsequently deployed. Despite a well-functioning TAVR and post-PCI TIMI III flow, the patient remained in ventricular fibrillation. Impella CP was alarming for low flow and intraoperative TEE demonstrated poor right ventricular function. An RP Impella was placed for concern of right ventricular failure. After placement of the RP Impella, she was converted to sinus rhythm and improved contractile function on TEE.
Conclusion: An important pathophysiologic mechanism in acute coronary obstruction following TAVI includes acute sinus sequestration. Pre-procedural CT evaluation is crucial in identifying at risk patients. Management often requires mechanical circulatory support with peripheral ECMO. However, we demonstrate successful management of circulatory collapse following acute coronary obstruction with Impella CP and RP.
