Abstract/Description
Title:
Cardiopulmonary Bypass Facilitates Emergent TAVR and Bifurcation PCI in a Highly Comorbid 72-year-old Female with Acute Valvular Shock
Introduction:
Transcatheter aortic valve replacement (TAVR) has emerged as a critical minimally invasive option for patients with severe AS who present in valvular shock, particularly those at prohibitive surgical risk. Multicenter registry data demonstrate that emergent TAVR in this population is associated with promising procedural success, significant improvements in functional status, and lower short- and long-term mortality compared to medical management or balloon aortic valvuloplasty, with outcomes approaching those of surgical aortic valve replacement in selected patients [1] [2]. We present a case of emergent TAVR and complex percutaneous coronary intervention (PCI) in a patient presenting with valvular cardiogenic shock complicated by myocardial ischemia.
Case Presentation:
A 72-year-old female with severe symptomatic aortic stenosis (mean gradient 65 mmHg, DI 0.2), extensive coronary artery disease, and ischemic cardiomyopathy presented with NSTE-ACS and valvular cardiogenic shock. Admission TEE confirmed acute reduction of LVEF to 20% (baseline 53%) and critical AS. After surgical risk was deemed prohibitive, she was stabilized with an IABP, and a multidisciplinary heart team planned a percutaneous valve replacement and coronary revascularization procedure on veno-arterial extracorporeal membrane oxygenation (V-A ECMO). During the procedure, attempts at left leaflet modification via UNICORN were unsuccessful due to extensive calcification and were complicated by a sinoatrial fistula. To mitigate risk of coronary obstruction, an Abbott Navitor™ valve was successfully deployed in an intentionally low position (6 mm below the annulus) using cusp-overlap technique, followed by culotte stenting of the left main-left circumflex bifurcation lesion through NavitorTM valve struts. The final result was excellent, with minimal paravalvular leak, mean gradient < 10 mmHg, and 0% stenosis remaining in stented coronary lesions.
Discussion:
This case highlights the expanding role of emergent TAVR in valvular shock patients who are otherwise inoperable. Coronary artery obstruction is a life-threatening complication of TAVR, and while leaflet modification techniques like BASILICA are primary prevention strategies, they can be unfeasible in the setting of severe calcification. Intentionally low transcatheter valve implantation is a viable alternative strategy to maintain coronary perfusion. The success of this complex procedure was predicated on a multidisciplinary heart team approach and robust hemodynamic support with V-A ECMO.
Conclusions:
Intentionally low valve implant is a crucial alternative technique to mitigate the risk of coronary obstruction when leaflet modification is not possible, expanding the procedural options for treating high-risk patients in cardiogenic shock. Advances in self-expanding valve design and operator experience increase ease of coronary access post-TAVR.
References:
-
Goel K, Shah P, Jones BM, et al. Outcomes of transcatheter aortic valve replacement in patients with cardiogenic shock. Eur Heart J. 2023;44(33):3181-3195. doi:10.1093/eurheartj/ehad387
-
Elkaryoni A, Cohen DJ, Lopez JJ, Huded CP, Kennedy KF, Arnold SV. Trends in invasive treatment of patients hospitalized with aortic stenosis complicated by cardiogenic shock. Catheter Cardiovasc Interv. 2022;100(6):1110-1116. doi:10.1002/ccd.30413
Faculty Advisor/Mentor
Dr. Matthew Summers, MD
Faculty Advisor/Mentor Email
mrsumme1@sentara.com
Faculty Advisor/Mentor Department
Structural Heart
College/School/Affiliation
Eastern Virginia Medical School (EVMS)
Included in
Cardiopulmonary Bypass Facilitates Emergent TAVR and Bifurcation PCI in a Highly Comorbid 72-year-old Female with Acute Valvular Shock
Title:
Cardiopulmonary Bypass Facilitates Emergent TAVR and Bifurcation PCI in a Highly Comorbid 72-year-old Female with Acute Valvular Shock
Introduction:
Transcatheter aortic valve replacement (TAVR) has emerged as a critical minimally invasive option for patients with severe AS who present in valvular shock, particularly those at prohibitive surgical risk. Multicenter registry data demonstrate that emergent TAVR in this population is associated with promising procedural success, significant improvements in functional status, and lower short- and long-term mortality compared to medical management or balloon aortic valvuloplasty, with outcomes approaching those of surgical aortic valve replacement in selected patients [1] [2]. We present a case of emergent TAVR and complex percutaneous coronary intervention (PCI) in a patient presenting with valvular cardiogenic shock complicated by myocardial ischemia.
Case Presentation:
A 72-year-old female with severe symptomatic aortic stenosis (mean gradient 65 mmHg, DI 0.2), extensive coronary artery disease, and ischemic cardiomyopathy presented with NSTE-ACS and valvular cardiogenic shock. Admission TEE confirmed acute reduction of LVEF to 20% (baseline 53%) and critical AS. After surgical risk was deemed prohibitive, she was stabilized with an IABP, and a multidisciplinary heart team planned a percutaneous valve replacement and coronary revascularization procedure on veno-arterial extracorporeal membrane oxygenation (V-A ECMO). During the procedure, attempts at left leaflet modification via UNICORN were unsuccessful due to extensive calcification and were complicated by a sinoatrial fistula. To mitigate risk of coronary obstruction, an Abbott Navitor™ valve was successfully deployed in an intentionally low position (6 mm below the annulus) using cusp-overlap technique, followed by culotte stenting of the left main-left circumflex bifurcation lesion through NavitorTM valve struts. The final result was excellent, with minimal paravalvular leak, mean gradient < 10 mmHg, and 0% stenosis remaining in stented coronary lesions.
Discussion:
This case highlights the expanding role of emergent TAVR in valvular shock patients who are otherwise inoperable. Coronary artery obstruction is a life-threatening complication of TAVR, and while leaflet modification techniques like BASILICA are primary prevention strategies, they can be unfeasible in the setting of severe calcification. Intentionally low transcatheter valve implantation is a viable alternative strategy to maintain coronary perfusion. The success of this complex procedure was predicated on a multidisciplinary heart team approach and robust hemodynamic support with V-A ECMO.
Conclusions:
Intentionally low valve implant is a crucial alternative technique to mitigate the risk of coronary obstruction when leaflet modification is not possible, expanding the procedural options for treating high-risk patients in cardiogenic shock. Advances in self-expanding valve design and operator experience increase ease of coronary access post-TAVR.
References:
-
Goel K, Shah P, Jones BM, et al. Outcomes of transcatheter aortic valve replacement in patients with cardiogenic shock. Eur Heart J. 2023;44(33):3181-3195. doi:10.1093/eurheartj/ehad387
-
Elkaryoni A, Cohen DJ, Lopez JJ, Huded CP, Kennedy KF, Arnold SV. Trends in invasive treatment of patients hospitalized with aortic stenosis complicated by cardiogenic shock. Catheter Cardiovasc Interv. 2022;100(6):1110-1116. doi:10.1002/ccd.30413