Percutaneous Aortic Valve Implantation in Patients with Coronary Artery Disease: Review of Therapeutic Strategies
- Volume 21 - Issue 12 - December, 2009
- Posted on: 12/7/09
- 0 Comments
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On physical examination at admission, a 3/6 systolic murmur was heard at the base of the heart. Echocardiography revealed good systolic left ventricular function with an ejection fraction of 60%. Significantly high gradients were noted over the aortic valve (99/59 mmHg), and the calculated valve area was 0.8 cm2. The diagnosis was severe aortic stenosis. There was mild aortic valve regurgitation and the ascending aorta was not dilated.
The patient was considered a very poor candidate for conventional aortic valve replacement surgery owing to her relatively advanced age, significant frailty, and reduced rehabilitation capacity secondary to the previous stroke. The logistic EuroSCORE predicted a 31% risk of mortality; the Logistic Parsonnet score was 35%. The patient was referred to our PAVI screening program and was found to be eligible for the procedure.
The patient underwent PAVI in March 2009. The procedure was performed under general anesthesia and continuous transesophageal echocardiography (TEE) monitoring. Coronary angiography, performed before the aortic valve was crossed with the guidewire, demonstrated no significant obstruction in the left coronary system (Figure 1A) and near-total occlusion of the proximal RCA stent (Figure 1B). After discussing the clinical situation, we opted for a single-stage procedure wherein we would perform PCI to the RCA and soon thereafter continue with PAVI as planned. The PCI was performed with a 15 x 3.5 mm scoring balloon at 12 atm inflation pressure (Figure 1C), with excellent angiographic results (Figure 1D). A stent was not deployed. Once good flow in the RCA was confirmed and the patient was hemodynamically stable, we completed the PAVI process. A temporary pacemaker was inserted to allow for rapid pacing and for potential heart block. Following mini-surgical cutdown in the groin, several balloon inflations were performed in the aortic valve. A 26 mm Edwards-Sapien balloon-expandable aortic valve (Edwards Lifesciences, Inc., Irvine, California) was then delivered through a 24 Fr introducer sheath (Figure 2A), and the balloon-valve complex was inflated under rapid ventricular pacing (220 Hz) (Figure 2B). Fluoroscopy and aortography revealed that the valve was in the exact position, with no paravalvular leakage, and that the coronary ostia were open (Figures 2C and 2D). On echocardiography, there was a decrease in the aortic valve gradients (from 102/72 to 11/6 mmHg) and an increase in the valve area (from 0.8 to 1.6 cm2). The vascular access was closed surgically.
The patient was transferred to the intensive care unit, and extubation was performed 2 hours later. One day after the procedure, the patient commenced ambulation. There was no evidence of significant vascular or hemorrhagic complications, arrhythmias, or conduction disturbances. The patient was discharged from the hospital 4 days after the procedure in excellent condition, with early evidence of significant clinical improvement. The improvement was sustained on clinical and echocardiographic follow up 2 months later.
Discussion. We report herein on a patient whose PCI was followed immediately by PAVI during the same interventional session. We need first to clarify several points in order to analyze the different possible strategies for the treatment of combined CAD and severe aortic stenosis in candidates for PAVI: