Abstract
Objectives
Percutaneous coronary intervention (PCI) after transcatheter aortic valve implantation (TAVI) can become technically challenging after implantation of the self-expanding Medtronic CoreValve (MCV) device, which completely covers the aortic root. The aim of this study was to report on the incidence, feasibility and outcome of PCI after TAVI with the MCV device.
Methods
Between 2007 and 2014, all patients subjected to PCI after MCV implantation in a single-center institutional TAVI database were retrospectively identified. Clinical, angiographic and procedural characteristics were reviewed and analyzed.
Results
We identified a total of 17 patients (5.7%) treated with 24 PCI procedures for 29 lesions at a median of 17.7 months (range 1–72) after MCV implantation. The mean age was 79.7 ± 6.8 years and the mean logistic EuroSCORE was 30.3% ± 18.9%. Nine procedures were performed for patients with acute coronary syndrome. 89.6% of the treated lesions were of type B2/C and 79.3% were de novo ones. A median of one guiding catheter was necessary to intubate the target coronary ostium (range 1–10) and 95% of the lesions on the left coronary artery were treated through a Judkins catheter. In one primary PCI for STEMI the intubation of the right coronary ostium was not successful. Final procedural success was obtained in 95.8%, and peri-procedural death occurred in one patient.
Conclusions
The need for PCI after MCV is not uncommon and is mostly related to coronary artery disease progression. PCI after MCV is usually feasible and safe, but coronary intubation in an emergency setting can be challenging.
Highlights
- •
PCI after TAVI with the self-expanding CoreValve device is mostly feasible and safe.
- •
Careful planning and understanding of the geometry of the prosthetic is required.
- •
Selective intubation of the coronary in an emergency setting could be challenging.
1
Introduction
Calcific aortic stenosis (AS) and atherosclerosis share common risk factors , and there is a frequent coincidence of AS and coronary artery disease (CAD) . As the prevalence of CAD increases with age , more than 50% of elderly AS patients undergoing transcatheter aortic valve implantation (TAVI) have co-existing CAD . The optimal treatment strategy for CAD in these patients is still controversial . Percutaneous coronary intervention (PCI) is commonly performed as a staged procedure before TAVI or combined with TAVI , but sometimes treatment of CAD is deferred . The decision is usually determined by the leading clinical problem, the complexity of the underlying CAD, patient’s co-morbidities and local practice. As CAD is a progressive disease, PCI after TAVI becomes sometimes necessary, which can be hampered and/or become technically challenging with certain device types.
The self-expanding Medtronic CoreValve device (Medtronic Inc., Minneapolis, MN, USA) is characterized by a long funnel-shaped nitinol stent frame that completely covers the aortic root . Despite a constrained waist that is designed to maintain coronary perfusion ( Fig. 1 ), the stent struts holding the bioprosthetic valve could alter the access to the coronary arteries. Sporadic descriptions of PCI after MCV have been previously reported , but no formal analyses of the incidence, feasibility and outcome have been described. In this retrospective single-center study, we report our experience with PCI performed after TAVI with the MCV device. We sought to investigate the incidence and clinical outcome, and have particularly focused on the feasibility and technical aspects of these procedures.
