1Deutsches Herzzentrum München Klinik für Herz- und Kreislauferkrankungen München, Deutschland
Background
Transcatheter aortic valve implantation (TAVI) within failed surgical bioprosthesis (referred to as valve-in-valve; ViV) has become an established treatment option over the last years. Although less invasive than re-operations, these procedures require careful patient selection and detailed pre-procedural planning. Certain risks, including coronary obstruction (CO) need to be considered. Deployment of a “prophylactic” coronary stent (referred to as chimney-stenting) in case of a high risk for coronary obstruction has become popular over time. Cases with acute coronary syndrome after chimney-stenting are rare and technical options are not standardized to date. Moreover, data on the intensity and duration of antithrombotic therapy after chimney-stenting are scarce.
Case report
A 73-year-old female patient was admitted for elective valve-in-valve TAVI after restenosis of a SJM Trifecta Bioprothesis (#19) implanted six years earlier. Previous medical diagnoses only included early childhood brain damage with intellectual disability. Hemodynamically relevant coronary stenoses were excluded in an earlier coronary angiography. Due to a small distance of only 5,4 mm between the ostium of the left main stem and the Trifecta Bioprosthesis, the procedure had a high risk of acute coronary artery obstruction. Successful TAVI procedure was performed with a Boston Acurate Neo S valve. To avoid coronary obstruction chimney-stenting with a 3,5x28 mm Xience stent was performed after valve deployment. An antithrombotic therapy with a NOAC and Clopidogrel (for at least 6 months) was recommended.
Ten months later, the patient was admitted to our chest-pain-unit with acute ST-elevation myocardial infarction (STEMI). Immediate coronary angiography showed a thrombotic occlusion of the left anterior descending artery due to stent thrombosis. Percutaneous coronary intervention with recanalization, PTCA and stenting (3.0x28mm) was performed with a good angiographic result. Technical issues due to chimney-stenting will be presented in case of acceptation of this case report. Patient was discharged with a triple therapie with a NOAC plus Aspirin and Clopidogrel for at least 12 months.
Conclusion
We present a rare case of acute STEMI after chimney-stenting in the setting of Valve-in-valve TAVI. Although, coronary access was challenging, successful PCI was performed with a good angiographic result. This case report further illuminates the technical challenges when re-access after chimney-stenting is necessary and gives the option to discuss optimal antithrombotic therapy in this patient population.