ABC | Volume 113, Nº6, December 2019

Case Report Emergent Percutaneous Rotational Atherectomy to Bailout Surgical Transapical Aortic Valve Implantation: A Successful Case of Heart Team Turnaround Tawfiq Choudhury, 1 Shahrukh N. Bakar, 1 B ob Kiaii, 1 Patrick Teefy 1 London Health Sciences Centre - Interventional Cardiology, 1 London, Ontario – Canada Mailing Address: Tawfiq Choudhury • London Health Sciences Centre - Interventional Cardiology - 339 Windermere Rd London London, Ontário N6A 5W9 – Canada E-mail: tawfiqc@hotmail.com Manuscript received July 09, 2018, revised manuscript November 16, 2018, accepted December 19,2018 Keywords Aortic Valve Stenosis; Atherectomy, Coronary; Atherectomy; Peripheral Arterial Disease; Coronary Angiography. DOI: 10.5935/abc.20190235 Abstract Transcatheter aortic valve implantation (TAVI) is an established treatment for severe aortic stenosis (AS) in patients with elevated surgical risk. Concomitant coronary artery disease affects 55-70% of patients with severe AS. Percutaneous coronary intervention in patients with TAVI can be challenging. We report a case of acute coronary obstruction immediately following transapical TAVI deployment requiring emergent rotational atherectomy. Introduction Transcatheter aortic valve implantation (TAVI) is an established treatment for severe aortic stenosis (AS) in patients with elevated surgical risk. Concomitant coronary artery disease affects 55-70% of patients with severe AS. 1 Percutaneous coronary intervention (PCI) in patients with TAVI can be challenging. Rotational atherectomy (RA) before or after TAVI has been described in an elective setting, but not as an emergent procedure. 2,3 Coronary artery occlusion or obstruction is a rare but serious complication of TAVI. We report a case of acute coronary obstruction immediately following transapical TAVI deployment requiring emergent RA to restore adequate perfusion. Case Report An 86-year-old male, with prior coronary artery bypass grafting and severe peripheral arterial disease (PAD), presented with New York Heart Association class III exertional dyspnea. Echocardiography revealed severe calcific AS with normal left ventricular systolic function. Cardiac computed tomography (CT) showed adequate left (14 mm) and right (21 mm) coronary heights. Previous coronary angiography had demonstrated non-occlusive triple-vessel coronary artery disease with a functional left internal mammary artery graft to the left anterior descending artery and a dominant native left circumflex artery. A Symetis Acurate ‘Large’ (Boston Scientific, Boston, MA, USA) TAVI prosthesis was deployed transapically in the hybrid operating theatre. Immediately thereafter, the patient became hypotensive and developed posterolateral ST‑segment elevation. Emergent coronary angiography showed a critical, calcific filling defect at the junction of the distal end of the short left mainstem and proximal-mid circumflex arteries (Figure 1, Panel A). Through the radial access, a 6-French Cordis XB 3.5 guide catheter (Cardinal Health, Vaughan, ON, Canada) was used to cannulate the left main coronary artery. Heparin was administered to maintain ACT > 250 seconds and clopidogrel 600mg was administered. The lesion resisted extensive attempts at balloon delivery. A 0.009” RotaWire Floppy guidewire was inserted to facilitate the 1.5 mm Rotablator Rotational Atherectomy System (Boston Scientific Corporation, Boston, MA, USA) burr passage at 180,000 rpm. Three passes were undertaken into the mid-circumflex artery (Figure 1, Panel B). A 2.5 x 20 mm non-compliant balloon was subsequently inserted unimpeded in the left main coronary artery (post-RA and balloon dilatation-figure 1, panel C) extending into the proximal circumflex segment over a Pilot 50 guidewire (Abbott Vascular, Abbott Park, IL, USA). A 3.25 x 38 mm Xience Xpedition (Abbott Vascular, Abbott Park, IL, USA) drug-eluting stent was successfully deployed extending from the ostium of the left main coronary artery into the proximal-mid circumflex lesions and post-dilated with a 3.5 x 20 mm non-compliant balloon at high pressures with a good angiographic result (Figure 1, Panel D) and resolution of electrocardiographic changes along with marked hemodynamic improvement. The patient subsequently recovered uneventfully in the intensive care unit and was extubated the following day and transferred to the ward uneventfully. Peak creatine kinase and high-sensitivity troponin T levels were 961 U/l and 1921 ng/l respectively. Comments PCI post-TAVI can be challenging. The case report describes emergency RA immediately after deployment of a transapical TAVI prosthesis and highlights the feasibility and challenges of complex, high-risk PCI in such patients. Choice of vascular access for PCI can be limited to only transradial in patients with severe PAD. Anatomical variants and tortuosity can impede guide manipulation. The valve prosthesis can obstruct coronary ostia or alter annular geometry and a trial with multiple guides might be necessary for selective engagement. Valves jailing the coronary ostia canmake selective intubation more difficult. 1 The Symetis Acurate TA TAVI prosthesis pulls the native valve leaflets away from the coronary ostia making coronary obstruction unlikely. 4 However, coronary flow can be compromised by displacement of annular calcium 1151