Page 37 - Journal of Structural Heart Disease Volume 5, Issue 2

Case Report 50
Figure 2. Intra vascular ultrasound demonstrating after initial stent placement demonstrating an ellipsoid geometry after initial stent placement (Panel A) and improved geometry after second stent placement (Panel B).
(Figure 2, Panel B). The wire was removed and final angiography was performed (Figure 1, Panel C). The patient had an uneventful post-procedure recovery. She was chest pain-free at rest and with ambulation and was discharged home the next day.
Discussion
Avoidance of coronary occlusion is obviously the optimal approach whenever feasible with TAVR, and this requires careful imaging, planning, and device selection [8]. Planning for a bailout strategy for a pa- tient at high risk of obstruction is critical. PCI with stent deployment can be employed to manage cor- onary occlusion in approximately 80% of patients [3]. The long-term concerns of a stent extruding into the aorta, especially behind the side cells of a TAVR valve, is stent patency and the ability to re-engage the stent for further treatment should this be necessary. A re- viewoftheliteraturedemonstratesthat,whilePCIof the left main de novo prior to and after TAVR has been performed, this is the first published case of repeat intervention through a snorkeled LM stent [9, 10].
One alternative consideration for a treatment op- tion was a surgical approach to revascularization,
such as a single vessel LIMA rather than PCI. Given the complexity of this case, a heart team approach was taken with a full discussion between the refer- ring cardiologist, the interventional cardiologist, and the cardiac surgeon regarding the best therapeutic approach. Her STS risk of mortality for the coronary bypass was calculated at 5.7%, driven largely by the acute progression of symptoms, prior cardiac surgery, cerebrovascular and peripheral arterial disease, gen- der, and morbid obesity.
The patient was deemed a poor surgical candidate, and it was determined that an attempt at PCI to re- solve her ischemia was warranted rather than directly proceeding to bypass. If further restenosis develops in the LM stent segment then CABG will likely be re- quired because of the complexity of the stent config- uration in the LM coronary artery.
Another consideration for treatment when there is a concern for a low-lying coronary ostium would be the BASILICA procedure (Bioprosthetic Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery obstruction) [7]. This would involve the intentional laceration of the bioprosthetic (in this case) valve leaflet prior to TAVR deployment in order to attempt to prevent iatrogenic coronary artery ob-
Journal of Structural Heart Disease, April 2019
Volume 5, Issue 2:48-51