Page 45 - Journal of Structural Heart Disease Volume 4, Issue 5

Case Report
Journal of Structural Heart Disease, October 2018, Volume 4, Issue 5:240-245
DOI: https://doi.org/10.12945/j.jshd.2018.008.18
Received: March 27, 2018 Accepted: April 19, 2018 Published online: October 2018
Left Main Protection and Emergency Stenting During TAVR with Self-Expandable Valve
Marko Noc, MD, PhD1,2*, Branko Cveticanin, MD1,3, Saibal Kar, MD1,4, Oscar A. Mendiz, MD1,5
1 MC Medicor, Izola, Slovenia
2 Center for Intensive Internal Medicine, University Medical Center, Ljubljana, Slovenia
3 Department of Radiology, General Hospital Izola, Izola, Slovenia
4 Cardiovascular Intervention Center, Cedars-Sinai Heart Institute, Los Angeles, California, United States
5 Interventional Cardiology Department, Cardiology & Cardiovascular Institute. Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
Abstract
Left main (LM) obstruction is rare but life-threaten- ing complication of transcatheter aortic valve replace- ment (TAVR) which occurs by displacement of left cor- onary leaflet toward the ostium or by direct occlusion by the covered skirt of the prosthesis. We report an 88- year old lady with severe aortic stenosis, short distance from annulus to left main origin, shallow/low sinus of Valsalva, and calcification of the left aortic leaflet un- dergoing TAVR with a self-expandable valve. Instead of recently described “Chimney” stenting with protrusion of a very long stent segment from LM above the pros- thesis leaflets and behind the valve frame, a “T-stent- ing” with stent protrusion only into the left sinus Val- salva was used to secure the LM patency.
Copyright © 2018 Science International Corp.
Key Words
Emergency left main stenting, TAVR
Introduction
Left main (LM) obstruction is rare but life-threat- ening complication of transcatheter aortic valve re- placement (TAVR) which occurs by displacement of left coronary leaflet over the ostium or by direct oc- clusion by the covered skirt of the prosthesis [1, 2].
Since this complication may be anticipated if a care- ful evaluation of aortic computed tomography (CT) scan is performed, LM can be protected up front by placement of a guiding catheter into the LM ostium and advancing a guidewire with undeployed stent into the left anterior descending artery (LAD) [2]. If LM occlusion occurs, the stent can be immediately withdrawn and deployed to reestablish LM patency. Importantly, because of the valve height during the TAVR with a self-expandable valve such as Evolut R (Core Valve Evolut R, Medtronic, Dublin, Ireland), the guiding catheter is located behind rather than above the valve frame. In case of LM occlusion, a "chimney" stenting with protrusion of a very long stent segment from the LM ostium above the prosthesis leaflets and behind the valve frame, has recently been described [3]. We herein present an alternative “T-stenting” strategy with stent protrusion extending only into the sinus of Valsalva toward the valve frame without leaving any stent segment behind the valve frame.
Case report
The patient was an 88-year-old lady with symp- tomatic severe aortic stenosis (gradient 69/37 mm Hg, AVA 0.4 cm2) and preserved left ventricular ejec-
* Corresponding Author:
Marko Noc, MD, PhD
Center for Intensive Internal Medicine
University Medical Center
Zaloska 7, 1000 Ljubljana, Slovenia
Tel. +386 41 723 807; Fax: +386 1 522 22 90; E-Mail: marko.noc@mf.uni-lj.si
Fax +1 203 785 3346
E-Mail: jshd@scienceinternational.org http://structuralheartdisease.org/
© 2018 Journal of Structural Heart Disease Published by Science International Corp. ISSN 2326-4004
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