Acute coronary obstruction following transcatheter aortic valve implantation: Small vessels, big problems

Transcatheter aortic valve implantation (TAVI) has become in this last decade an alternative treatment to surgery in patients with severe symptomatic aortic stenosis (AS), with a high or prohibitive surgical risk [ [1] Rodes-Cabau J. Transcatheter aortic valve implantation: current and future approaches. Nat. Rev. Cardiol. 2011; 9: 15-29 Crossref PubMed Scopus (260) Google Scholar ]. Despite advances in the development of new devices and the growing experience of centers performing the procedure, the implant is not exempt of risks. Among the potential complications, acute coronary obstruction (CO) represents a rare complication (<1%), but with a high morbidity and mortality [ [2] Ribeiro H.B. Webb J.G. Makkar R.R. Cohen M.G. Kapadia S.R. Kodali S. et al. Predictive factors, management, and clinical outcomes of coronary obstruction following transcatheter aortic valve implantation: insights from a large multicenter registry. J. Am. Coll. Cardiol. Oct 22 2013; 62: 1552-1562 Abstract Full Text Full Text PDF PubMed Scopus (393) Google Scholar ]. In the majority of the reported cases, the main mechanism of the obstruction is a displacement of the calcified native valve leaflets over the main coronary ostia. The left coronary artery ostium is more frequently affected (~88%) due to its anatomical arrangement [ 2 Ribeiro H.B. Webb J.G. Makkar R.R. Cohen M.G. Kapadia S.R. Kodali S. et al. Predictive factors, management, and clinical outcomes of coronary obstruction following transcatheter aortic valve implantation: insights from a large multicenter registry. J. Am. Coll. Cardiol. Oct 22 2013; 62: 1552-1562 Abstract Full Text Full Text PDF PubMed Scopus (393) Google Scholar , 3 Ribeiro H.B. Nombela-Franco L. Urena M. Mok M. Pasian S. Doyle D. et al. Coronary obstruction following transcatheter aortic valve implantation: a systematic review. JACC Cardiovasc. Interv. May 2013; 6: 452-456 Abstract Full Text Full Text PDF PubMed Scopus (205) Google Scholar ]. Given the significant quantity of ischemic myocardium caused by a left main occlusion, the clinical manifestations are substantial, presented as maintained severe arterial hypotension, electrocardiographic changes (mainly alterations of the ST segment) and/or malignant ventricular arrhythmias [ 2 Ribeiro H.B. Webb J.G. Makkar R.R. Cohen M.G. Kapadia S.R. Kodali S. et al. Predictive factors, management, and clinical outcomes of coronary obstruction following transcatheter aortic valve implantation: insights from a large multicenter registry. J. Am. Coll. Cardiol. Oct 22 2013; 62: 1552-1562 Abstract Full Text Full Text PDF PubMed Scopus (393) Google Scholar , 3 Ribeiro H.B. Nombela-Franco L. Urena M. Mok M. Pasian S. Doyle D. et al. Coronary obstruction following transcatheter aortic valve implantation: a systematic review. JACC Cardiovasc. Interv. May 2013; 6: 452-456 Abstract Full Text Full Text PDF PubMed Scopus (205) Google Scholar , 4 Ye J. Coronary artery occlusion as a complication of transcatheter aortic valve implantation. Can. J. Cardiol. Sep-Oct 2012; 28: 534-536 Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar ]. However, we are reporting two cases of acute CO following TAVI that, despite occurring in non-dominant and secondary vessels, were complicated by cardiogenic shock and massive mitral (MR) and tricuspid regurgitation (TR).