Right coronary occlusion following transcatheter aortic valve implantation: two case reports

Abstract

This paper discusses two male patients with severe aortic stenosis, whose right coronary arteries (RCA) were completely occluded during transcatheter aortic valve implantation (TAVI), leading to fatal hemodynamic disorder. Occlusions of RCA complicated by TAVI are rare. In addition, emergency cardiopulmonary bypass (CPB) played a critical role in rescuing our second patient. Both patients were admitted for “severe aortic stenosis,” and TAVIs were performed. The first patient’s blood pressure immediately dropped to 70/40 mmHg after the balloon expansion and did not increase much after the administration of aramine or fluid therapy. He did not receive emergency surgery and died after 1.5 h of resuscitation. The second patient’s blood pressure fluctuated greatly for several minutes after the valve implantation, ranging from 170/100 mmHg to 60/40 mmHg. Angiography revealed a total occlusion of RCA. Thoracic surgery with CPB was performed, and the patient survived.

Keywords

aortic stenosis / transcatheter aortic valve implantation / right coronary occlusion / cardiac group

Introduction

Degenerative aortic stenosis is one of the most common cardiac vascular diseases. For high-risk patients (age>75 years, left ventricular ejection fraction<40%), transcatheter aortic valve implantation (TAVI) may be preferable to the traditional surgical alternative [ 1]. However, TAVI still has many complications and the most severe one is the occlusion of the coronary artery. The incidence of this complication is often increased by many factors such as the calcified native leaflet, low coronary ostium, or the balloon-expandable valve. The coronary ostium is frequently obstructed by the displacement of the calcified valve cusp. In our two cases with severe calcified leaflet, right coronary arteries were obstructed, leading to fatal hemodynamic disorder and requiring emergency percutaneous coronary intervention (PCI), extracorporeal membrane oxygenation (ECMO), or cardiopulmonary bypass (CPB). Heart teams, including interventional cardiologist, cardiac surgeon, vascular surgeon, cardiac anesthesiologist, and cardiac imaging doctor, have potential to improve the quality of patient care.

Case 1

A 76-year-old male patient presented with a history of recurring chest pains for more than 20 years and chest distress for more than 2 years. He was admitted for aortic stenosis and was scheduled for TAVI. Chest CT showed obvious and severe calcification of the aortic valve and aorta. Echocardiography showed severe aortic stenosis, moderate aortic and tricuspid regurgitation, and mild mitral and pulmonary regurgitation. Preoperative coronary angiography showed right coronary artery patency (Fig. 1).

Before the operation, the baseline vital signs of the patient were monitored: BP was 164/85 mmHg, HR was 124 bpm, and SpO₂ was 91%. Anesthesia was intravenously induced with midazolam, sufentanil, etomidate, and rocuronium; and it was maintained with sevoflurane and a continuous infusion of remifentanil. After about 10 min, a transesophageal echocardiograph (TEE) probe was inserted. About 1.5 h after the operation, a balloon was expanded. Subsequently, HR decreased to 60 bpm, and BP decreased to 70/40 mmHg. BP did not increase much after administration of vasopressor agent boluses. At the same time, the autonomic HR became slower, and TEE showed no contractions in the right ventricle. Ventriculography also showed no blood flow into the right coronary artery, while the left one remained open (Fig. 2). Both collapsed circulation and the ventriculography findings indicated that the right coronary artery might be obstructed by the native calcified valve. To keep the circulation stable, we set the pacemaker to 80 bpm, administered a vasopressor agent, and kept blood volume stable via CVP. However, when the operation changed to cardiothoracic surgery, TEE indicated no forward blood flow and the monitor showed ventricular fibrillation. Even after repeated defibrillation and cardiopulmonary resuscitation (CPR), no response was observed from TEE or radiography (Fig. 3). After 1.5 h of resuscitation, the patient was declared clinically dead.

Case 2

A 76-year-old male patient suffered from recurring chest pain and distress for more than 15 years and was admitted for “severe aortic stenosis.” Preoperational echocardiography showed severe aortic stenosis and mild to moderate aortic regurgitation. CT showed a severely calcified aortic valve. According to the parameters from the CT (Fig. 4), the average diameter of the aortic annulus was less than 26 mm. The manufacturer of Venus Medtech A-Valve, a self-expandable valve from Qiming, Hangzhou, China (Fig. 5), recommended the proper prosthetic valve according to the diameter of aortic annulus (Table 1). For the second patient, the average diameter was less than 26 mm, and the #29 prosthestic valve was recommended [ 2].

Anesthesia was induced with midazolam, sufentanil, propofol, and rocuroniumand maintained with sevoflurane and a continuous infusion of remifentanil. A TEE probe and a temporary pacemaker probe were inserted. After about 2 h of operation, balloon valvuloplasty was performed and an aortic valve was inserted. According to TEE, the prosthetic valve functioned well. Coronary angiography displayed that the right coronary artery was unobstructed (Fig. 6). A few minutes later, blood pressure changed dramatically with the contraction of the left ventricle, varying from 170/100 mmHg to 60/40 mmHg. Coronary angiography confirmed that no blood was flowing into the right coronary artery (Fig. 6), which might be obstructed by the native calcified valve. To maintain stable circulation, a continuous infusion of adrenaline and a supply of fluid infusion with CVP were administered. Ensuring the airway and anesthesia machine were functional, anesthesiologists focused on the monitor and prepared to defibrillate. When the interventional doctors and cardiologists failed to remove the valve with interventional treatment, the cardiac surgeon performed urgent thoracic aortic replacement with CPB. The vital signs of the patient were normal after the CPB (BP of 100/70 mmHg, HR of 100 bpm, SpO₂ of 100%), and he was sent to the ICU and stayed there for 4 days. Twenty days later, he was discharged from the hospital and recovered well without any complications.

Discussion

In both cases, we encountered the unexpected occurrence of fatal hemodynamic collapse. One developed immediately after balloon dilatation; the other occurred after an aortic valve placement. Both patients suffered obstruction of the right coronary artery.

Pasic et al. also reported a serious complication of TAVI: annular rupture. This complication could also lead to circulatory failure and need to be diagnosed by TEE and angiography. According to the image manifestations, neither subtle nor aggressive evidence of annular rupture, such as extravasation, hematoma, or pericardial tamponade, exists. As a result, we excluded the rupture and made a definitive diagnosis of right coronary occlusion [ 3].

Given our patients’ poor conditions, traditional thoracic surgery was too risky. According to the 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease, TAVI is a safe and effective procedure for old patients with severe aortic stenosis who are in poor condition [ 4]. Many complications (including aortic regurgitation and atrioventricular block) may occur during this procedure. However, coronary obstruction, which is first reported in 2006, is very rare with an incidence of 0.2%–0.4% and requires urgent management [ 1, 5]. Females (about 83% of the cases) are more vulnerable to coronary obstruction, and the left coronary artery (88% of the complications) is more frequently affected [ 6, 7]. As stated, both our patients were male and both had their right coronary arteries affected, making their cases rare. Recent study revealed that risk factors such as low coronary ostia and severe calcified valve leaflet (both can be evaluated by preoperative CT scans of the heart) may contribute to this complication. Furthermore, when the length from the ostium to the aortic annulus is shorter than 10.6 mm (normal range is 13‒15 mm), the incidence of coronary occlusion dramatically increases. For our second patient, the length was only 11.8 mm (Fig. 7), which is consistent with the findings of Ribeiro et al. [ 8]. They also stated that the most frequent mechanism with coronary obstruction was the displacement of the calcified valve cusp covering the coronary ostium [ 1]. Therefore, low coronary ostium or calcified native cusps should not be overlooked.

Measurements should be taken to prevent the occurrence of coronary occlusion. First, CT scan of heart is essential because it can provide very detailed information about the valves (for example, the diameter of aortic annulus), enabling us to choose the proper prosthetic valve. Self-expandable valves have also shown better performance than the balloon-expandable ones (the incidences of coronary occlusion are<0.2% and>0.4%, respectively) [ 9, 10]. Moreover, self-expandable valves could reduce the risk of annular rupture [ 3].

When circulation worsens, coronary occlusion should be suspected and emergency angiography of the coronary arteries should be performed. Once coronary occlusion is confirmed, treatments should be performed. First and foremost, the cooperation of interventional cardiologists, cardiac surgeons, heart physicians, and anesthesiologists in our hybrid operation room is imperative [ 11]. Second, emergency PCI, thoracic surgery with CPB, and ECMO should be implemented. When this complication occurs, corresponding interventional treatments are crucial for favorable outcomes [ 12]. Some doctors have found PCI successful in 90% of patients who suffered coronary obstruction. Ribeiro et al. also attempted PCI in 75% of their cases, and 81.8% of the patients survived [ 8]. Thus, PCI is an excellent way to cure this severe complication. Other doctors often effectively use CPB or ECMO to rescue the patient, as shown by the second case we reported. Miniaturized ECMO systems can be safe and highly effective in restoring circulation and gas exchange in patients with cardiopulmonary failure. Finally, pharmacotherapy including vasopressor agents and fluid infusion can ensure coronary perfusion.

In conclusion, risk factors such as low coronary ostia and severe calcified valve leaflet may increase the incidence of coronary occlusion, and we should also have preventive measures against this severe complication. Above all, this complication requires a positive diagnosis and emergency treatments from the cooperation of a cardiac group in the hybrid operation room.

References

[1] Ribeiro HB, Nombela-Franco L, Urena M, Mok M, Pasian S, Doyle D, DeLarochellière R, Côté M, Laflamme L, DeLarochellière H, Allende R, Dumont E, Rodés-Cabau J. Coronary obstruction following transcatheter aortic valve implantation: a systematic review. JACC Cardiovasc Interv 2013; 6(5): 452–461

[2] Wang MY, Xu L, Pei HJ, Teng SY, Zhang HT, Lv B, Wang H, Yang YJ, Wu YJ. Aortic root imaging and clinical application in 15 patients with transcatheter aortic valve implantation — a single center early experience. Chin Circ J (Zhongguo Xun Huan Za Zhi) 2014; 29: 714–717

[3] Pasic M, Unbehaun A, Buz S, Drews T, Hetzer R. Annular rupture during transcatheter aortic valve replacement: classification, pathophysiology, diagnostics, treatment approaches, and prevention. JACC Cardiovasc Interv 2015; 8(11 Pt A): 1–9

[4] Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM 3rd, Thomas JD. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary—a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 10; 63(22):2438–2488

[5] Stabile E, Sorropago G, Cioppa A, Cota L, Agrusta M, Lucchetti V, Rubino P. Acute left main obstructions following TAVI. EuroIntervention 2010; 6(1): 100–105

[6] Seipelt RG, Hanekop GG, Schoendube FA, Schillinger W. Heart team approach for transcatheter aortic valve implantation procedures complicated by coronary artery occlusion. Interact Cardiovasc Thorac Surg 2012; 14(4): 431–433

[7] Franco A, Gerli C, Ruggeri L, Monaco F. Anaesthetic management of transcatheter aortic valve implantation. Ann Card Anaesth 2012; 15(1): 54–63

[8] Ribeiro HB, Webb JG, Makkar RR, Cohen MG, Kapadia SR, Kodali S, Tamburino C, Barbanti M, Chakravarty T, Jilaihawi H, Paradis JM, de Brito FS Jr, Cánovas SJ, Cheema AN, de Jaegere PP, del Valle R, Chiam PT, Moreno R, Pradas G, Ruel M, Salgado-Fernández J, Sarmento-Leite R, Toeg HD, Velianou JL, Zajarias A, Babaliaros V, Cura F, Dager AE, Manoharan G, Lerakis S, Pichard AD, Radhakrishnan S, Perin MA, Dumont E, Larose E, Pasian SG, Nombela-Franco L, Urena M, Tuzcu EM, Leon MB, Amat-Santos IJ, Leipsic J, Rodés-Cabau J. Predictive factors, management, and clinical outcomes of coronary obstruction following transcatheter aortic valve implantation: insights from a large multicenter registry. J Am Coll Cardiol 2013; 62(17): 1552–1562

[9] Rodés-Cabau J, Webb JG, Cheung A, Ye J, Dumont E, Feindel CM, Osten M, Natarajan MK, Velianou JL, Martucci G, DeVarennes B, Chisholm R, Peterson MD, Lichtenstein SV, Nietlispach F, Doyle D, DeLarochellière R, Teoh K, Chu V, Dancea A, Lachapelle K, Cheema A, Latter D, Horlick E. Transcatheter aortic valve implantation for the treatment of severe symptomatic aortic stenosis in patients at very high or prohibitive surgical risk: acute and late outcomes of the multicenter Canadian experience. J Am Coll Cardiol 2010; 55(11): 1080–1090

[10] Thomas M, Schymik G, Walther T, Himbert D, Lefèvre T, Treede H, Eggebrecht H, Rubino P, Michev I, Lange R, Anderson WN, Wendler O. Thirty-day results of the SAPIEN Aortic Bioprosthesis European Outcome (SOURCE) Registry: a European registry of transcatheter aortic valve implantation using the Edwards SAPIEN valve. Circulation 2010; 122(1): 62–69 doi:10.1161/CIRCULATIONAHA.109.907402 PMID:20566953

[11] Crimi G, Passerone G, Rubartelli P. Trans-apical aortic valve implantation complicated by left main occlusion. Catheter Cardiovasc Interv 2011; 78(4): 656–659

[12] Ruggeri L, Gerli C, Franco A, Barile L, Magnano di San Lio MS, Villari N, Zangrillo A. Anesthetic management for percutaneous aortic valve implantation: an overview of worldwide experiences. HSR Proc Intensive Care Cardiovasc Anesth 2012; 4(1): 40–46

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