Partial Left Main Coronary Artery Obstruction Due to Migration of a Bioprosthetic Aortic Valve 60 Days After Transcatheter Aortic Valve Replacement: A Rare Clinical Case

TL;DR

A patient developed a rare complication two months after a heart valve replacement, leading to severe heart issues and ultimately death.

Contribution

This case report highlights a rare delayed complication of TAVR involving bioprosthetic valve migration causing coronary obstruction.

Findings

A self-expandable valve implanted during TAVR migrated upwards, causing partial left main coronary artery obstruction.

The patient developed severe myocardial ischemia and cardiogenic shock 60 days post-TAVR.

Interventional attempts to treat the obstruction failed, and the patient died during bypass surgery.

Abstract

Transcatheter aortic valve replacement (TAVR) offers a less invasive treatment alternative to surgical aortic valve replacement for high-risk patients. Although the procedure can be performed at low risk, life-threatening complications may arise in single cases during or even months after the procedure. Coronary obstruction has long been recognized as a potential complication of TAVR and is generally understood to occur within seconds or minutes after valve deployment. However, a few case reports have described the development of delayed coronary obstruction (DCO) occurring in the hours and days following the procedure. This is a case report of an 81-year-old patient who underwent TAVR due to aortic stenosis. The high implantation of a self-expandable valve, considered acceptable at the time of implantation, was eventually associated with severe myocardial ischemia that became clinically evident almost two months later. The patient underwent TAVR successfully, although the final aortogram revealed a somewhat high implant position. However, 50 days after the implantation, the patient started complaining of daily episodes of angina, dyspnea, and hypotension. She was admitted to the hospital 10 days later, and that day she developed a similar angina episode, followed by pulmonary edema and cardiogenic shock. The patient rapidly improved with intravenous vasoconstrictors and stabilized with the use of an intra-aortic balloon pump. A transthoracic echocardiogram (TTE) revealed a well-functioning prosthetic valve. An aortic root angiogram revealed patent coronary arteries. However, the non-coronary sinus of Valsalva (SOV) was barely opacified, and the left SOV was filling through a slit as a result of a prosthetic valve that had gradually migrated upwards in the sinotubular junction (STJ). This, in turn, resulted in compromised blood flow to the left main (LM) coronary artery ostium. The obstruction was gradually worsening over time, leading to myocardial ischemia and cardiogenic shock. An attempt was made to treat this condition interventionally by trying to cross into the left SOV and catheterize the LM ostium with the intention of percutaneous coronary intervention (PCI) treatment, but it was not successful. After these failed attempts, the decision was made to proceed with a bypass graft implantation to the left anterior descending artery, with off-pump surgery. Regrettably, the patient did not survive the operation.

Figures