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Kissing balloon inflation in the aortic valve and left main stem: A novel coronary protection technique
International Journal of Cardiology 223 (2016) 571–573
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
Kissing balloon inflation in the aortic valve and left main stem: A novel coronary protection technique Toru Naganuma a,⁎, Satoru Mitomo a, Hiroto Yabushita a, Hiroyoshi Kawamoto a, Tatsuya Nakao b, Aleksandar Lazarevic a,c, Sunao Nakamura a a b c
Department of Cardiology, New Tokyo Hospital, Chiba, Japan Department of Cardiovascular Surgery, New Tokyo Hospital, Chiba, Japan University Clinical Center Banja Luka, Banja Luca, Bosnia and Herzegovina
a r t i c l e
i n f o
Article history: Received 29 July 2016 Accepted 8 August 2016 Available online 9 August 2016 Keywords: Coronary obstruction Kissing balloon inflation Transcatheter aortic valve implantation
Coronary obstruction is a rare but life-threatening complication of transcatheter aortic valve implantation (TAVI) [1,2]. In patients at high risk of obstruction, techniques to consider include coronary ostium stenting, guidewire protection, and catheter cannulation [1,3,4]. We report a novel “Kissing Balloon Inflation” (KBI) technique to secure coronary protection in a patient with low left-main height. A 94-year-old woman was diagnosed with severe aortic stenosis (Fig. 1A). Her height and weight were 136 cm and 36 kg, respectively. Transthoracic echocardiography revealed aortic valve area of 0.4 cm2 and mean aortic valve pressure gradient (AVPG) of 63 mmHg. Mild aortic regurgitation was detected, with decreased left ventricular ejection fraction (42%). Computed tomography (CT) showed left-main height of only 7.7 mm (Fig. 1B). Due to hemodynamic instability, she underwent emergent intra-aortic balloon pump placement and subsequent transfemoral TAVI. Because of the risk of obstruction, a decision was made to secure left-main protection. A 3.5 × 12 mm Xience Alpine (Abbott Vascular, Santa Clara, CA) was implanted with intentional protrusion into the sinus of Valsalva (Fig. 1C–D). Then, pre-dilation
⁎ Corresponding author at: New Tokyo Hospital, 1271 Wanagaya, Matsudo, Chiba, Japan. E-mail address: [email protected] (T. Naganuma).
http://dx.doi.org/10.1016/j.ijcard.2016.08.187 0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved.
with KBI was performed using a 15-mm balloon in the aortic valve and a 3.0-mm balloon in the left main (Fig. 1E). Finally, a 23-mm Sapien 3 (Edwards Lifesciences, Irvine, CA, USA) was successfully deployed using KBI technique (Fig. 1F), with immediate hemodynamic improvement. There was no evidence of left-main obstruction despite the presence of calcified masses on the left coronary cusp leaflet near the proximal part of the stent (Fig. 1G, 2A–D). Post-procedural echocardiography showed a well-seated prosthesis with an acceptable AVPG (16 mmHg) and a mild paravalvular leak. One-week CT confirmed successful left-main protection using KBI technique. Our case highlights the feasibility of this novel technique in the presence of low left-main height for successful TAVI. Conflict of interest statement Dr. Naganuma is a proctor for transfemoral-TAVI for Edwards SAPIEN-XT and -3 valves. References [1] H.B. Ribeiro, J.G. Webb, R.R. Makkar, M.G. Cohen, S.R. Kapadia, S. Kodali, 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. 62 (2013) 1552–1562. [2] H. Eggebrecht, A. Schmermund, P. Kahlert, R. Erbel, T. Voigtlander, R.H. Mehta, Emergent cardiac surgery during transcatheter aortic valve implantation (TAVI): a weighted meta-analysis of 9251 patients from 46 studies, EuroIntervention. 8 (2013) 1072–1080. [3] Y. Abramowitz, T. Chakravarty, H. Jilaihawi, M. Kashif, Y. Kazuno, N. Takahashi, et al., Clinical impact of coronary protection during transcatheter aortic valve implantation: first reported series of patients, EuroIntervention. 11 (2015) 572–581. [4] M. Yamamoto, T. Shimura, S. Kano, A. Kagase, A. Kodama, Y. Koyama, et al., Impact of preparatory coronary protection in patients at high anatomical risk of acute coronary obstruction during transcatheter aortic valve implantation, Int. J. Cardiol. 217 (2016) 58–63.
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Correspondence
Fig. 1. A. CT showing calcification on LCC leaflet (dotted red circle) B. CT showing low LM height (7.7 mm) C: Aortography in perpendicular view D: Successful implantation of Xience Alpine 3.5 × 12 mm with intentional protrusion into SOV, followed by post-dilation with 4.0-mm non-compliant balloon E: Pre-dilation with KBI technique using 15-mm balloon in the aortic valve and 3.0-mm balloon in the LM F: Successful deployment of a 23-mm Sapien 3 with KBI technique G: No evidence of left-main occlusion CT = computed tomography, KBI = kissing balloon inflation, LCC = left coronary cusp, LM = left main, NCC = non-coronary cusp, RCC = right coronary cusp, SOV = sinus of Valsalva.
Correspondence
573
Fig. 2. A: Longitudinal IVUS view after Sapien 3 deployment, showing 2.5-mm stent protrusion into SOV and calcification on the LCC leaflet near the proximal part of the stent B. Short axis IVUS view showing adequate stent expansion C. Short axis IVUS view showing calcified masses on the LCC leaflet (dotted red circle) near the proximal part of the stent D. Post-procedural transesophageal echocardiography showing protrusion of Xience stent (dotted yellow lines) into SOV and position of Sapien 3 valve (dotted green circle) E, F: CT at 1-week follow-up confirming successful expansion of Sapien 3 valve and Xience stent, with calcification on the LCC leaflet (dotted red circle) very close to the Xience stent (dotted yellow circle) CT = computed tomography, IVUS = intravascular ultrasound, LCC = left coronary cusp, LM = left main, NCC = non-coronary cusp, RCC = right coronary cusp, SOV = sinus of Valsalva.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
Kissing balloon inflation in the aortic valve and left main stem: A novel coronary protection technique Toru Naganuma a,⁎, Satoru Mitomo a, Hiroto Yabushita a, Hiroyoshi Kawamoto a, Tatsuya Nakao b, Aleksandar Lazarevic a,c, Sunao Nakamura a a b c
Department of Cardiology, New Tokyo Hospital, Chiba, Japan Department of Cardiovascular Surgery, New Tokyo Hospital, Chiba, Japan University Clinical Center Banja Luka, Banja Luca, Bosnia and Herzegovina
a r t i c l e
i n f o
Article history: Received 29 July 2016 Accepted 8 August 2016 Available online 9 August 2016 Keywords: Coronary obstruction Kissing balloon inflation Transcatheter aortic valve implantation
Coronary obstruction is a rare but life-threatening complication of transcatheter aortic valve implantation (TAVI) [1,2]. In patients at high risk of obstruction, techniques to consider include coronary ostium stenting, guidewire protection, and catheter cannulation [1,3,4]. We report a novel “Kissing Balloon Inflation” (KBI) technique to secure coronary protection in a patient with low left-main height. A 94-year-old woman was diagnosed with severe aortic stenosis (Fig. 1A). Her height and weight were 136 cm and 36 kg, respectively. Transthoracic echocardiography revealed aortic valve area of 0.4 cm2 and mean aortic valve pressure gradient (AVPG) of 63 mmHg. Mild aortic regurgitation was detected, with decreased left ventricular ejection fraction (42%). Computed tomography (CT) showed left-main height of only 7.7 mm (Fig. 1B). Due to hemodynamic instability, she underwent emergent intra-aortic balloon pump placement and subsequent transfemoral TAVI. Because of the risk of obstruction, a decision was made to secure left-main protection. A 3.5 × 12 mm Xience Alpine (Abbott Vascular, Santa Clara, CA) was implanted with intentional protrusion into the sinus of Valsalva (Fig. 1C–D). Then, pre-dilation
⁎ Corresponding author at: New Tokyo Hospital, 1271 Wanagaya, Matsudo, Chiba, Japan. E-mail address: [email protected] (T. Naganuma).
http://dx.doi.org/10.1016/j.ijcard.2016.08.187 0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved.
with KBI was performed using a 15-mm balloon in the aortic valve and a 3.0-mm balloon in the left main (Fig. 1E). Finally, a 23-mm Sapien 3 (Edwards Lifesciences, Irvine, CA, USA) was successfully deployed using KBI technique (Fig. 1F), with immediate hemodynamic improvement. There was no evidence of left-main obstruction despite the presence of calcified masses on the left coronary cusp leaflet near the proximal part of the stent (Fig. 1G, 2A–D). Post-procedural echocardiography showed a well-seated prosthesis with an acceptable AVPG (16 mmHg) and a mild paravalvular leak. One-week CT confirmed successful left-main protection using KBI technique. Our case highlights the feasibility of this novel technique in the presence of low left-main height for successful TAVI. Conflict of interest statement Dr. Naganuma is a proctor for transfemoral-TAVI for Edwards SAPIEN-XT and -3 valves. References [1] H.B. Ribeiro, J.G. Webb, R.R. Makkar, M.G. Cohen, S.R. Kapadia, S. Kodali, 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. 62 (2013) 1552–1562. [2] H. Eggebrecht, A. Schmermund, P. Kahlert, R. Erbel, T. Voigtlander, R.H. Mehta, Emergent cardiac surgery during transcatheter aortic valve implantation (TAVI): a weighted meta-analysis of 9251 patients from 46 studies, EuroIntervention. 8 (2013) 1072–1080. [3] Y. Abramowitz, T. Chakravarty, H. Jilaihawi, M. Kashif, Y. Kazuno, N. Takahashi, et al., Clinical impact of coronary protection during transcatheter aortic valve implantation: first reported series of patients, EuroIntervention. 11 (2015) 572–581. [4] M. Yamamoto, T. Shimura, S. Kano, A. Kagase, A. Kodama, Y. Koyama, et al., Impact of preparatory coronary protection in patients at high anatomical risk of acute coronary obstruction during transcatheter aortic valve implantation, Int. J. Cardiol. 217 (2016) 58–63.
572
Correspondence
Fig. 1. A. CT showing calcification on LCC leaflet (dotted red circle) B. CT showing low LM height (7.7 mm) C: Aortography in perpendicular view D: Successful implantation of Xience Alpine 3.5 × 12 mm with intentional protrusion into SOV, followed by post-dilation with 4.0-mm non-compliant balloon E: Pre-dilation with KBI technique using 15-mm balloon in the aortic valve and 3.0-mm balloon in the LM F: Successful deployment of a 23-mm Sapien 3 with KBI technique G: No evidence of left-main occlusion CT = computed tomography, KBI = kissing balloon inflation, LCC = left coronary cusp, LM = left main, NCC = non-coronary cusp, RCC = right coronary cusp, SOV = sinus of Valsalva.
Correspondence
573
Fig. 2. A: Longitudinal IVUS view after Sapien 3 deployment, showing 2.5-mm stent protrusion into SOV and calcification on the LCC leaflet near the proximal part of the stent B. Short axis IVUS view showing adequate stent expansion C. Short axis IVUS view showing calcified masses on the LCC leaflet (dotted red circle) near the proximal part of the stent D. Post-procedural transesophageal echocardiography showing protrusion of Xience stent (dotted yellow lines) into SOV and position of Sapien 3 valve (dotted green circle) E, F: CT at 1-week follow-up confirming successful expansion of Sapien 3 valve and Xience stent, with calcification on the LCC leaflet (dotted red circle) very close to the Xience stent (dotted yellow circle) CT = computed tomography, IVUS = intravascular ultrasound, LCC = left coronary cusp, LM = left main, NCC = non-coronary cusp, RCC = right coronary cusp, SOV = sinus of Valsalva.