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Heart, Lung and Circulation (2014) 23, e142–e144 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2013.12.012

Trans-Aortic Percutaneous Heart Valve Deployment of Impella CPTM to Assist in High-Risk Percutaneous Coronary Intervention William Chan, MBBS, PhD*, Peter H. Seidelin, MBChB, MD Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada Received 6 July 2013; received in revised form 16 December 2013; accepted 24 December 2013; online published-ahead-of-print 24 January 2014

Keywords

Aortic stenosis  Transcatheter aortic valve implant  Impella CP  Left main  Percutaneous coronary intervention  In-stent restenosis

The use of left ventricular haemodynamic assist devices during high-risk percutaneous coronary intervention (PCI) remains controversial and is currently only recommended in certain subsets of high-risk patients according to the 2011 American College of Cardiology/American Heart Association/Society of Cardiovascular Angiography and Interventions PCI guidelines (class IIb, level of evidence C) [1]. We present a case of an 82 year-old woman who required urgent revascularisation of her saphenous vein graft (SVG) in-stent restenosis (ISR). She previously underwent two thoracotomies for aortocoronary bypass (right internal thoracic artery to right coronary artery in 2005 and SVG to obtuse marginal via the descending aorta as the ascending aorta was known to be prohibitively calcific in 2012); and transpical delivery of a 23 mm Edwards SAPIENTM (Edwards Lifesciences, Irvine, CA) valve in 2008. Her current non-ST elevation myocardial infarction relates to the severe SVG ISR in the setting of flush left main occlusion following five previous attempts at treating left main ISR with drug-eluting stents, cutting and drugeluting balloons (Fig. 1). The right internal thoracic artery to right coronary artery bypass graft remained patent and left ventricular systolic function was preserved (estimated

ejection fraction by echocardiography and cardiac catheterisation was about 55%). Given the severity of her disease (SVG-dependent left coronary circulation), and prohibitive surgical risk (calculated Society of Thoracic Surgeons’ [STS] mortality risk score of 12%, version 2.73), transcatheter haemodynamic support was utilised. In addition, we were concerned for the potential complication of no-reflow during PCI of the SVG lesion due to distal embolisation, which might cause further abrupt deterioration in haemodynamics. A 14Fr Impella CPTM (Abiomed, Danvers, MA) was inserted via the left femoral artery in preference to an intra-aortic balloon pump as the latter might interfere with PCI procedure in the descending aorta. The Impella CPTM was carefully positioned across the Edwards SAPIENTM valve without difficulty and augmented well during the procedure (Fig. 2). Post PCI echocardiography revealed no evidence of aortic regurgitation. This case highlights the use of the Impella device in high-risk PCI post TAVI. The effect of the rotary pump on the Edwards SAPIENTM valve is unknown with potential for valve disruption as has been reported rarely in the literature when this device was deployed across native aortic valves [2].

* Corresponding author at: University Health Network, Toronto General Hospital, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada. Tel.: +416 340-4930; fax: +416 340-3865., Emails: [email protected], [email protected] © 2014 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.

Impella support for PCI post TAVI

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Figure 1 A). Flush occlusion of the left main ostium. B). Severe obliterative fibrotic response at aorto-ostial junction of left main causing previously deployed drug-eluting stents to assume a wine glass appearance. C). Aortogram confirms flush occlusion of left main stem (arrow). The native right coronary artery can be seen filling (arrow). D). Severe in-stent restenosis of previously stented saphenous vein graft segment supplying the left circumflex obtuse marginal. A porcelain aorta is clearly seen.

Figure 2 A). Impella CPTM successfully deployed through a 23 mm Edwards SAPIENTM percutaneous heart valve. B) Successful stenting of saphenous vein graft in-stent restenosis with a 2.75/38 mm everolimus-eluting stent. Retrograde backfilling of the occluded left main and severely stenosed ostial left anterior descending artery is seen (arrow).

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Funding sources Dr. Chan is supported by the National Health and Medical Research Council of Australia Early Career Fellowship (Neil Hamilton Fairley – Clinical Overseas Fellowship) (APP1052960).

Disclosures No conflicts of interest to declare.

W. Chan, P.H. Seidelin

References [1] Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation 2011;124: e574–651. [2] Chandola R, Cusimano R, Osten M, Horlick E. Postcardiac transplant transcatheter core valve implantation for aortic insufficiency secondary to Impella device placement. Ann Thorac Surg 2012;93:e155–7.

Trans-aortic percutaneous heart valve deployment of Impella CP(TM) to assist in high-risk percutaneous coronary intervention.

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