Page 35 - Journal of Structural Heart Disease Volume 5, Issue 2

Case Report
Journal of Structural Heart Disease, April 2019, Volume 5, Issue 2:48-51
DOI: https://doi.org/10.12945/j.jshd.2019.030.18
Received: September 09, 2018 Accepted: September 15, 2018 Published online: April 2019
Stenting the Snorkel: PCI of a Restenosed Left
Main Stent Placed for Coronary Obstruction after
Valve in Valve TAVR
Hazim El-Haddad, MD, Jon Resar, MD*
Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
Abstract
Acute coronary artery occlusion is a known compli- cation of transcatheter aortic valve replacement. One bailout strategy to treat acute coronary artery occlu- sion is deployment of a “snorkel” stent from the coro- nary artery behind the TAVR valve. While this approach will restore coronary artery patency, the long-term concern of this method is the ability to re-intervene on the stented coronary artery in the future. We demon- strate the complexity of re-intervention in a case of acute coronary syndrome due to ostial restenosis of a “snorkel” stent.
Copyright © 2019 Science International Corp.
Key Words
TAVR • Left Main intervention • Percutaneous coronary intervention
Introduction
Transcatheter Aortic Valve Replacement (TAVR) is a well-established alternative to surgical aortic valve replacement for the treatment of aortic stenosis. As the indications for TAVR have expanded from prohib- itive, high, and intermediate risk patients to clinical trials in low-risk patients, and as the overall popula- tion ages, the procedure is becoming increasingly common [1]. As such, it is important to be familiar with the possible risks of TAVR. A known risk of TAVR is
coronary obstruction by the native valve (or biopros- thetic surgical valve) leaflets after deployment of the TAVR valve. Although the incidence is relatively un- common (<1%), the consequence of acute coronary occlusion can be devastating, with a mortality risk as high as 40% [2, 3]. It is a risk that should be carefully considered and planned for during TAVR, especially if the coronary ostium originates less than 12 mm from the plane of the valve annulus, and particularly in the Medtronic self-expanding valves, which extend above the coronary ostia by design [4, 5]. The risk of coronary occlusion is increased for valve-in-valve pro- cedures compared to native aortic valves and may be up to 3.5% [4]. Additionally, the height of the coro- nary ostium is not as straightforward a guide as in a native valve, due to the variable relationship between the native annulus and the bioprosthetic leaflets, and careful imaging is critical in order to understand the patient-specific anatomy [6]. The most common treatment strategy in the event of coronary obstruc- tion during TAVR is PCI with stent deployment, and this is associated with a >90% success rate [4]. This is generally performed by pulling back and deploying a stent that has been pre-delivered to the coronary artery. Another novel option is intentional laceration of the aortic valve leaflet (BASILICA) [7]. With TAVR be- coming increasingly common as the indications have expanded, so too will patients returning with coro- nary artery disease requiring intervention after TAVR.
* Corresponding Author:
Jon Resar, MD
Division of Cardiology
Johns Hopkins University School of Medicine
1800 Orleans St, Baltimore, MD 21287, USA
Tel. +1 410 614 1132; Fax: +1 443 287 3180; E-Mail: jresar@jhmi.edu
Fax +1 203 785 3346
E-Mail: jshd@scienceinternational.org http://structuralheartdisease.org/
© 2019 Journal of Structural Heart Disease Published by Science International Corp. ISSN 2326-4004
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