JACC: CARDIOVASCULAR INTERVENTIONS
VOL. 8, NO. 2, 2015
ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER INC.
ISSN 1936-8798/$36.00 http://dx.doi.org/10.1016/j.jcin.2013.11.030
IMAGES IN INTERVENTION
Successful Repositioning of a Direct Flow Medical 25-mm Valve due to Acute Occlusion of Right Coronary Artery During Transcatheter Aortic Valve Replacement Procedure Alexander Wolf, MD,* Thomas Schmitz, MD,* Azeem Latib, MD,y Christoph K. Naber, MD*
A
76-year-old female patient with symptomatic
tomography scan noted a low origin of the right
severe aortic stenosis was referred for trans-
coronary artery (7 mm) (Figure 1). The heart team
catheter aortic valve replacement (TAVR)
due to high risk for open-heart surgery (logistic
F I G U R E 2 Occluded RCA
EuroSCORE [European System for Cardiac Operative Risk Evaluation] 23.6%) (1,2). Screening computed
F I G U R E 1 Multislice CT Scan Sagittal View
Angiographic image (left anterior oblique 10 , cranial 14 ) after first inflation of the aortic ring of the Direct Flow 25-mm valve Transcatheter aortic valve replacement screening computed
(Online Video 1). The left ventricular outflow tract ring is sealing
tomography (CT) workup revealed a low origin of right coronary
with no trance of aortic regurgitation (Online Video 2). The aortic
artery (7 mm).
ring is occluding the ostium of the right coronary artery (RCA).
From the *Department of Cardiology, Contilia Heart and Vascular Center, Elisabeth-Krankenhaus, Essen, Germany; and the ySan Raffaele Scientific Institute, Milan, Italy. Dr. Latib is a consultant for Direct Flow; and serves on Medtronic’s advisory board. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received November 4, 2013; accepted November 7, 2013.
e34
Wolf et al.
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 8, NO. 2, 2015 FEBRUARY 2015:e33–4
Repositioning of Valve During TAVR
F I G U R E 3 Repositioning of the Valve
F I G U R E 4 Selective Angiogram of RCA
Angiographic image (left anterior oblique 10 , cranial 14 )
Angiographic image (left anterior oblique 20 , cranial 20 ) after
showing deflation of the aortic ring (Online Video 3). The part of
valve repositioning. Selective angiography revealed no coronary
the valve near the native noncoronary cusp and right coronary
compromise (Online Video 4). RCA ¼ right coronary artery.
cusp was pushed toward the left ventricular outflow tract. The valve was realigned again and inflated.
was discharged at day 7 and 30-day follow-up was uneventful. decided to perform transfemoral TAVR with implan-
The Direct Flow valve is a second-generation
tation of a repositionable valve (Direct Flow, Direct
repositionable and retrievable TAVR device that of-
Flow Medical Inc., Santa Rosa, California).
fers advantages in avoiding periprocedural compli-
A 25-mm Direct Flow valve was deployed, but
cations such as paravalvular leak and acute coronary
angiography revealed occlusion of the right coronary
occlusion (4). Intraprocedural anatomic and func-
artery (Figure 2, Online Videos 1 and 2). Deflation and
tional assessment can be obtained before finalizing
repositioning the part of the valve near the native
valve positioning. Complications such as acute coro-
noncoronary cusp and right coronary cusp toward the
nary occlusion may no longer be an issue with repo-
left ventricular outflow tract was performed (Figure 3,
sitionable second-generation TAVR devices.
Online Video 3). After this realignment, the valve was expanded again and selective angiography confirmed
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
no compromise of the right coronary artery (Figure 4,
Alexander Wolf, Contilia Heart and Vascular Center,
Online Video 4). There was no evidence of peri-
Klara Kopp Weg 1, 45138 Essen, Germany. E-mail:
procedural myocardial infarction (3). The patient
[email protected].
REFERENCES 1. Smith CR, Leon MB, Mack MJ, et al., for the PARTNER Trial Investigators. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med 2011;364:
3. Généreux P, Head SJ, Van Meighem NM, et al. Clinical outcomes after transcatheter aortic valve replacement using Valve Academic Research Consortium definitions. J Am Coll Cardiol 2012;59:
2187–98.
2317–26.
KEY WORDS aortic valve stenosis, coronary occlusion, low origin of right coronary artery, transcatheter aortic valve replacement
2. Leon MB, Smith CR, Mack M, et al., for the PARTNER Trial Investigators. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med 2010;363: 1597–607.
4. Généreux P, Webb JG, Svensson LG, et al., for the PARTNER Trial Investigators. Vascular complications after transcatheter aortic valve replacement: insights from the PARTNER (Placement of AoRTic TraNscathetER Valve) trial. J Am Coll Cardiol 2012;60:1043–52.
AP PE NDIX For accompanying videos, please see the online version of this article.
VOL. 8, NO. 2, 2015
ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER INC.
ISSN 1936-8798/$36.00 http://dx.doi.org/10.1016/j.jcin.2013.11.030
IMAGES IN INTERVENTION
Successful Repositioning of a Direct Flow Medical 25-mm Valve due to Acute Occlusion of Right Coronary Artery During Transcatheter Aortic Valve Replacement Procedure Alexander Wolf, MD,* Thomas Schmitz, MD,* Azeem Latib, MD,y Christoph K. Naber, MD*
A
76-year-old female patient with symptomatic
tomography scan noted a low origin of the right
severe aortic stenosis was referred for trans-
coronary artery (7 mm) (Figure 1). The heart team
catheter aortic valve replacement (TAVR)
due to high risk for open-heart surgery (logistic
F I G U R E 2 Occluded RCA
EuroSCORE [European System for Cardiac Operative Risk Evaluation] 23.6%) (1,2). Screening computed
F I G U R E 1 Multislice CT Scan Sagittal View
Angiographic image (left anterior oblique 10 , cranial 14 ) after first inflation of the aortic ring of the Direct Flow 25-mm valve Transcatheter aortic valve replacement screening computed
(Online Video 1). The left ventricular outflow tract ring is sealing
tomography (CT) workup revealed a low origin of right coronary
with no trance of aortic regurgitation (Online Video 2). The aortic
artery (7 mm).
ring is occluding the ostium of the right coronary artery (RCA).
From the *Department of Cardiology, Contilia Heart and Vascular Center, Elisabeth-Krankenhaus, Essen, Germany; and the ySan Raffaele Scientific Institute, Milan, Italy. Dr. Latib is a consultant for Direct Flow; and serves on Medtronic’s advisory board. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received November 4, 2013; accepted November 7, 2013.
e34
Wolf et al.
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 8, NO. 2, 2015 FEBRUARY 2015:e33–4
Repositioning of Valve During TAVR
F I G U R E 3 Repositioning of the Valve
F I G U R E 4 Selective Angiogram of RCA
Angiographic image (left anterior oblique 10 , cranial 14 )
Angiographic image (left anterior oblique 20 , cranial 20 ) after
showing deflation of the aortic ring (Online Video 3). The part of
valve repositioning. Selective angiography revealed no coronary
the valve near the native noncoronary cusp and right coronary
compromise (Online Video 4). RCA ¼ right coronary artery.
cusp was pushed toward the left ventricular outflow tract. The valve was realigned again and inflated.
was discharged at day 7 and 30-day follow-up was uneventful. decided to perform transfemoral TAVR with implan-
The Direct Flow valve is a second-generation
tation of a repositionable valve (Direct Flow, Direct
repositionable and retrievable TAVR device that of-
Flow Medical Inc., Santa Rosa, California).
fers advantages in avoiding periprocedural compli-
A 25-mm Direct Flow valve was deployed, but
cations such as paravalvular leak and acute coronary
angiography revealed occlusion of the right coronary
occlusion (4). Intraprocedural anatomic and func-
artery (Figure 2, Online Videos 1 and 2). Deflation and
tional assessment can be obtained before finalizing
repositioning the part of the valve near the native
valve positioning. Complications such as acute coro-
noncoronary cusp and right coronary cusp toward the
nary occlusion may no longer be an issue with repo-
left ventricular outflow tract was performed (Figure 3,
sitionable second-generation TAVR devices.
Online Video 3). After this realignment, the valve was expanded again and selective angiography confirmed
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
no compromise of the right coronary artery (Figure 4,
Alexander Wolf, Contilia Heart and Vascular Center,
Online Video 4). There was no evidence of peri-
Klara Kopp Weg 1, 45138 Essen, Germany. E-mail:
procedural myocardial infarction (3). The patient
[email protected].
REFERENCES 1. Smith CR, Leon MB, Mack MJ, et al., for the PARTNER Trial Investigators. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med 2011;364:
3. Généreux P, Head SJ, Van Meighem NM, et al. Clinical outcomes after transcatheter aortic valve replacement using Valve Academic Research Consortium definitions. J Am Coll Cardiol 2012;59:
2187–98.
2317–26.
KEY WORDS aortic valve stenosis, coronary occlusion, low origin of right coronary artery, transcatheter aortic valve replacement
2. Leon MB, Smith CR, Mack M, et al., for the PARTNER Trial Investigators. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med 2010;363: 1597–607.
4. Généreux P, Webb JG, Svensson LG, et al., for the PARTNER Trial Investigators. Vascular complications after transcatheter aortic valve replacement: insights from the PARTNER (Placement of AoRTic TraNscathetER Valve) trial. J Am Coll Cardiol 2012;60:1043–52.
AP PE NDIX For accompanying videos, please see the online version of this article.
