Page 38 - Journal of Structural Heart Disease Volume 5, Issue 5

231 Case Report
Figure 3. High coronary occlusion risk: Virtual THV coronary distance 3.1 mm for Edwards 23 mm S3 valve and 2.6 mm for Edwards 26 mm valve.
9.6. Another challenge was possibility of the patient declining to undergo redo cardiac surgery. The pa- tient was evaluated for the transcatheter approach. A computed tomography (CT) scan was performed to evaluate the patient’s suitability for the VIV procedure and evaluate procedural risks, including coronary oc- clusion (as cited in Dvir et al., 2015).
The manufacturer profile for the patient’s 25 mm Carpentier-Edwards Magna pericardial valve provides a true diameter of 23 mm and posts elevation of 17 mm. The true identifier for the patient’s aortic valve prothesis as measured by CT scan was 21.7 mm by 23.9 mm with an average of 22.8 mm. The sinotubu- lar junction height was 16.4 mm, which was slightly lower than the surgical valve posts. The average di- ameter was 28.4 mm. The left main coronary ostial height was low at 5.9 mm and the right coronary os- tial height was also low at 8.5 mm (Figure 2).
Both the VIV application and the CT evaluation suggested a 26 mm expandable Edwards SAPIEN 3 balloon and transcatheter valve or a 26 mm self-ex- panding CoreValve. These are the two valves avail- able in the United States.
There is concern about the future difficulty ac- cessing the low coronary arteries with very low ostial height in this patient. The sinus of Valsalva is narrow, while the sinotubular junction height is both low and narrow as compared to the surgical posts height. This made the balloon expandable EDWARDS SAPIEN 3 valve more desirable. However, the patient was at very high risk for both left main and right coronary
artery occlusions (as cited in Dvir et al., 2015). High risk criteria in this case includes: first, the VTC distance (virtual THV to coronary distance), as the virtual THV ring to the left main coronary ostia. The distance was 2.6 mm for a 26 mm EDWARDS SAPIEN3 valve and a 3.1 mm for a 23 mm SAPIEN3 valve (Figure 1). Second, a slightly tilted surgical prosthesis compared to the aortic root long axis. Third, the surgical frame posts are higher than the sinotubular junction at 17 mm versus 16.4 mm. Fourth, a very low coronary ostial height (Figure 3). Fifth, very small sinuses and stenot- ic valve pathology (Figure 3).
Coronary occlusion risk was discussed with the pa- tient and surgical options were readdressed. Howev- er, the patient again declined the redo high risk surgi- cal approach. The patient was offered a transfer to an institution. This institution is capable of splitting the aortic valve surgical prosthesis leaflets to reduce the risk of coronary occlusion (BASILICA procedure) (as cited in Khan et al., 2018). This option was declined due to family circumstances related to travel. This re- sulted in the patient consenting to the high risk cor- onary occlusion valve-in-valve TAVR. The following strategies were planned to perform this high coro- nary occlusion risk valve-in-valve TAVR case. Strat- egy one is undersizing by using a smaller THV valve at 23 mm rather than 26 mm. Strategy two is using a slightly lower deployment. Strategy three is placing coronary stents in the mid LAD and mid RCA prophy- lactically as a bail out option if coronary occlusion or compromised flow occurs.
Kassas S. et al.
Entrapment of Coronary Stent Catheter in VIV/TAVR