PMC9231540_01
(a) Preprocedural transesophageal echocardiography showing a continuous wave Doppler image of severe aortic stenosis. (b) Coronary angiogram showing normal perfusion of left coronary arteries before transcatheter aortic valve implantation
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F1
Echocardiography evaluation showed severe aortic valve stenosis (mean gradient 47 mmHg, aortic valve area 0.6 cm2), trivial aortic valve regurgitation, and left ventricular ejection fraction (LVEF) of 48% [Figure 1a]. Significant coronary artery disease was excluded by coronary angiography [Figure 1b].
Coronary computed tomography angiography showing the size of (a) Aortic annulus perimeter, (b) sinuses of valsalva diameter, (c) left ventricular outflow tract perimeter, (d) Distance of the right coronary ostia from aortic annulus plane. (e) Distance of the left main coronary ostia from aortic annulus plane. (f) Calcification of aortic cusps
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F2
Following the standard protocol for TAVI workup, a cardiac computerized tomography angiography (CTA) was performed, which suggested adequate coronary heights (16 mm for left main coronary and 19 mm for the right coronary artery [RCA] ostium), aortic annulus perimeter of 82.9 mm, sinuses of Valsalva measurements of 29.3 mm x 31.7 mm x 28.0 mm, with heavily calcified aortic valve leaflets [Figure 2].
(a) X-ray fluoroscopy demonstrating balloon valvuloplasty for the native aortic valve (white arrow). (b) Aortic angiogram showed the flow of contrast to the main right and left coronary arteries. (white arrows). (c) Selective left coronary artery angiogram demonstrated total occlusion of middle left anterior descending artery (white arrow). (d) X-ray fluoroscopy demonstrating thrombus aspiration by using the aspiration catheter. (e) Left coronary artery angiogram showing successful left anterior descending angioplasty with TIMI III flow (white arrow). (f) Fluoroscopic view of Evolut-R prosthesis after valve release (white arrow)
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F3
ACT level of 280. A 25 mm balloon (NuMED NuCLEUS ) was advanced through the right femoral artery sheath and inflated under rapid ventricular pacing at 160 beats per minute [Figure 3a] which was associated with mild balloon instability and movement of the balloon in and out at annular plane/left ventricular outflow tract-level during the maximum inflation because of inadequate rapid pacing. Angiography of the aortic root was performed which demonstrated patent RCA and left main coronary artery Ostia [Figure 3b]. Instantaneously, coronary angiography of the left coronary arteries was performed, which depicted total occlusion of proximal LAD artery by an embolic material [Figure 3c]. Manual aspiration of the culprit thrombus was performed using Export AP aspiration catheter [Figure 3d] resulting in successful coronary reperfusion (TIMI 3 flow) [Figure 3e], restoration of LV systolic function, and rapid hemodynamic improvement. Subsequently, a self-expanding 29 mm bioprosthetic valve (Evolut-R) was deployed within the native aortic valve [Figure 3f].