Abstract
Aims
High-risk patients with severe aortic stenosis (AS) who are candidates for transcatheter valve implantation (TAVI) or balloon aortic valvuloplasty (BAV) may additionally require revascularization of the unprotected left main coronary artery (UPLM). We aimed to assess the feasibility and procedural safety of UPLM stenting in such patients.
Methods and Results
Ten cases of UPLM stenting prior to BAV or TAVI at three medical centers over a 2-year period were identified. Mean age was 84±4 years, aortic valve area was 0.70±0.12 cm 2 , left ventricular ejection fraction was 58%±3%, and logistic EuroScore was 32±17. Intraaortic balloon counterpulsation was used in three patients. A single stent was used in seven patients, and two stents were used in three patients. One patient received a bare-metal stent, and the others received drug-eluting stents. No procedural complications occurred, and the patients were hemodynamically stable. Three patients subsequently underwent BAV, and seven underwent TAVI. During 6 months of follow-up, two patients died: one due to AS restenosis 6 months after BAV and one due to vascular complications 18 days after TAVI (34 days after UPLM stenting).
Conclusions
Stenting of the UPLM in patients with severe AS prior to percutaneous valve intervention seems feasible and safe. This approach may enable more patients to achieve comprehensive percutaneous therapy for severe coronary and valvular disease.
1
Introduction
An increasing number of high-risk patients with severe aortic stenosis (AS) are ineligible for surgical aortic valve replacement (AVR). The aortic valve may be treated percutaneously in these patients who may undergo either definitive valve therapy with transcatheter aortic valve implantation (TAVI) or palliative balloon aortic valvuloplasty (BAV) . Obstructive unprotected left main coronary artery (UPLM) lesions have been traditionally treated with coronary bypass surgery (CABG); however, percutaneous coronary interventions (PCIs) are increasingly being performed in this location . Stenting of the UPLM in patients with severe AS who are not surgical candidates presents unique challenges regarding procedural safety since these patients have very limited cardiovascular reserve and induction of even brief myocardial ischemia within a large myocardial territory during PCI may potentially lead to acute hemodynamic decompensation and death. An increasing number of patients with both AS and obstructive UPLM disease are candidates for combined percutaneous valve therapy and PCI; however, the safety of PCI in these patients has not been previously described.
2
Methods
2.1
Study population
We analyzed the databases of the interventional laboratories of three centers (Lady Davis Carmel, Tel Aviv Sourasky, and Chaim Sheba Medical Centers) for all cases in which patients with severe AS underwent UPLM stenting prior to BAV or TAVI. All patients were screened by a heart team which included a cardiologist, anesthetist, and cardiac surgeon who determined that the surgical risk was unacceptable. Increased surgical risk was based on an expected surgical mortality ≥20% based on the EuroScore or on the presence of severe comorbidities.
2.2
Study definitions
Significant UPLM obstruction was determined as the presence of >50% stenosis by coronary angiography or a luminal cross-sectional area <6 mm 2 by intravascular ultrasound (IVUS) imaging. Severe AS was defined as an aortic valve area <1.0 cm 2 in the presence of New York Heart Association (NYHA) heart failure symptoms class ≥II.
2.3
Study procedures
Vascular access site, stenting technique (single vs. double stenting) and use of intraaortic balloon counterpulsation (IABP), temporary pacemaker, and IVUS imaging guidance were based on the patient characteristics and operator preferences. Stent selection (drug-eluting vs. bare-metal stent) was individualized by the operators on the basis of the estimated risk of restenosis and the likelihood that the patients would be able to take long-term dual antiplatelet therapy. Choice of percutaneous valve therapy was based on the availability of TAVI at the time of treatment and the presence of contraindications for TAVI such as inadequate vascular access. The TAVI procedures involved implantation of the CoreValve ReValving system (Medtronic, Minneapolis, MN, USA). All patients were followed up by the treating physicians for 6 months.
2
Methods
2.1
Study population
We analyzed the databases of the interventional laboratories of three centers (Lady Davis Carmel, Tel Aviv Sourasky, and Chaim Sheba Medical Centers) for all cases in which patients with severe AS underwent UPLM stenting prior to BAV or TAVI. All patients were screened by a heart team which included a cardiologist, anesthetist, and cardiac surgeon who determined that the surgical risk was unacceptable. Increased surgical risk was based on an expected surgical mortality ≥20% based on the EuroScore or on the presence of severe comorbidities.
2.2
Study definitions
Significant UPLM obstruction was determined as the presence of >50% stenosis by coronary angiography or a luminal cross-sectional area <6 mm 2 by intravascular ultrasound (IVUS) imaging. Severe AS was defined as an aortic valve area <1.0 cm 2 in the presence of New York Heart Association (NYHA) heart failure symptoms class ≥II.
2.3
Study procedures
Vascular access site, stenting technique (single vs. double stenting) and use of intraaortic balloon counterpulsation (IABP), temporary pacemaker, and IVUS imaging guidance were based on the patient characteristics and operator preferences. Stent selection (drug-eluting vs. bare-metal stent) was individualized by the operators on the basis of the estimated risk of restenosis and the likelihood that the patients would be able to take long-term dual antiplatelet therapy. Choice of percutaneous valve therapy was based on the availability of TAVI at the time of treatment and the presence of contraindications for TAVI such as inadequate vascular access. The TAVI procedures involved implantation of the CoreValve ReValving system (Medtronic, Minneapolis, MN, USA). All patients were followed up by the treating physicians for 6 months.
3
Results
3.1
Patient characteristics
Ten patients with severe AS underwent UPLM stenting prior to BAV or TAVI ( Table 1 ). This cohort comprised 2% of all patients who underwent aortic valve percutaneous interventions at the participating medical centers during the study period. Eight (80%) of the patients were female. Mean age was 84±4 years, aortic valve area was 0.70±0.12 cm 2 , left ventricular ejection fraction was 58%±3%, and logistic EuroScore was 32±17. Two patients had previously undergone CABG: in one patient, all the grafts were occluded, and a second patient had only received a graft to the right coronary artery. Two patients had chronic occlusions of the right coronary artery at the time of UPLM stenting. Location of the UPLM lesions was ostial in four and distal in six patients.
| Patient # | Logistic EuroScore | Vascular access | Balloon pump | Lesion location | Stents | AS therapy |
|---|---|---|---|---|---|---|
| 1 | 40 | Femoral | Yes | Distal | Xience 3.5×18 mm | BAV |
| 2 | 13 | Femoral | No | Distal | Endeavor 3.0×30 mm | BAV |
| 3 | 60 | Brachial | Yes | Ostial | Promus 3.0×10 mm | BAV |
| 4 | 13 | Femoral | Yes | Ostial | SKS: Promus 3.5×15 mm, Promus 4.0×15 mm | TAVI |
| 5 | 9 | Radial | No | Ostial | Resolute 4.0×9 mm | TAVI |
| 6 | 20 | Femoral | No | Ostial | Driver 4.5×9 mm | TAVI |
| 7 | 49 | Femoral | No | Distal | Cypher 3.5×18 mm | TAVI |
| 8 | 35 | Radial | No | Distal | Culotte: Cypher 3.5×18 mm, Cypher 3.5×18 mm | TAVI |
| 9 | 45 | Radial | No | Distal | Culotte: Resolute 3.5×22 mm, Resolute 3.0×16 mm | TAVI |
| 10 | 35 | Radial | No | Distal | Cypher 3.5×18 mm | TAVI |
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