Delayed coronary obstruction following Portico in Freedom Solo valve-in-valve implantation
An 80-year-old woman (Society of Thoracic Surgeons score 5.3%) was admitted because of gradual onset of exertional dyspnea and angina 10 years after surgical aortic valve replacement with a 23 mm Sorin Freedom Solo (FS) stentless valve. Echocardiography indicated significant prosthesis degeneration, with severe stenosis. The heart team debated a percutaneous valve-in-valve (ViV) procedure against reoperation and the decision was made to implant a 27 mm St. Jude Medical Portico after computed tomography-based sizing (height of the coronaries to annular plane: left coronary artery: 14 mm, right coronary artery: 11 mm, aortic valve area 413 mm2; Supplementary Fig. 1, Supplemental digital content 1, http://links.lww.com/MCA/A135). The procedure was performed in sedoanalgesia with a good angiographic (Panel A, Supplementary Video 1, Supplemental digital content 2, http://links.lww.com/MCA/A136) and echocardiographic result. Eight days after discharge, the patient was seen because of recent-onset angina in recumbent positions. Although echocardiography showed normal prosthesis function, ECG changes were noted, with recurrent episodes of coronary T wave inversions in the anterior chest leads (Supplementary Fig. 2, Supplemental digital content 3, http://links.lww.com/MCA/A137). MSCT documented FS leaflets floating in front of the left main (LM) coronary ostium (Fig. 1) (Panel B). Selective coronary angiography confirmed subtotal occlusion of the LM coronary ostium with residual valve tissue (Panel C, Supplementary Video 2, Supplemental digital content 4, http://links.lww.com/MCA/A138). A drug-eluting stent (resolute integrity 4.5/12 mm) was deployed between the LM coronary artery and the Portico cage to exclude residual leaflet tissue (Panel D and E, Supplementary Video 3, Supplemental digital content 5, http://links.lww.com/MCA/A139 and Supplementary Video 4, Supplemental digital content 6, http://links.lww.com/MCA/A140). ECG changes disappeared after the procedure and the patient was discharged 5 days later in a good and stable condition.
The FS valve shows higher leaflet coaptation compared with stented bioprostheses. Elongated FS leaflets markedly increase the risk for ostial coronary artery obstruction after ViV-transcatheter aortic implantation (TAVI) 1,2. Techniques of pre-emptive LM protection have been described for valve-in-stentless-valve procedures 3. Furthermore, this case describes for the first time a potential for late-onset ostial coronary artery obstruction following ViV-TAVI and reinforces the importance of close monitoring and follow-up examinations within the weeks after TAVI.