PMC10099844_01
Failed engagement of the LMCA ostium with (A) Judkins Left 4.0 and (B) Multipurpose two diagnostic catheters. (C) Left and (D) right superior oblique view showing supra-TAVR LMCA engagement with a Judkins Left 4.0 guide catheter. Notice the calcified structure (pinned leaflet) in front of the LMCA (black arrow) and the position of the commissural posts (white arrows). Left superior oblique view of the LMCA (E) during predilation with 4.0 x 15 mm NC balloon at 20 atm (F) during inflation of a 4.0 x 12 mm IVL balloon at 4 atm, (G) just before deployment of the first stent (H) during flaring of the first 5.0 x 15 mm stent at the STJ-LMCA transition at 18 atm, (I) after deployment of the first stent and (J) after multistenting. Cx, circumflex; IVL, intravascular lithotripsy; LAD, left anterior descending; LMCA, left main coronary artery; TAVR, transcatheter aortic valve replacement; STJ, sinotubular junction.
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Coronary angiography was attempted in the referring hospital, but a selective engagement of the coronary ostia was considered impossible using both Judkins Left (Figure 1A) and Multipurpose (Figure 1B) diagnostic catheters. A second coronary angiography performed in our center revealed a critical ostial stenosis of the LMCA (Figure 1C,D and Supporting Information: Video 1). TAVR struts (Figure 1E-J). The transition of the sinotubular junction (STJ) to the LMCA (containing the pinned calcified leaflet) was predilated with 2.5 mm and 4.0 x 15 mm noncompliant balloons inflated up to 20 atm (Figure 1E). Because the balloons expanded inadequately, a 4.0 x 12 mm IVL balloon (Shockwave C2; Shockwave Medical) was inflated at 4 atm and 80 pulses were delivered at the site of stenosis (Figure 1F). Thereafter, a 5.0 x 15 mm drug-eluting stent (Resolute Onyx; Medtronic) was placed at 16 atm and ostial flare was performed with the stent balloon at 18 atm (Figure 1G,H). However, control angiography showed significant stent recoil (Figure 1I).
(A, B) Computed tomography frontal plane view of the aortic root and LMCA, showing the pinned down calcified AVR leaflet (red dotted outline) in front of the LMCA (yellow dotted outline). Notice that the TAVR frame (green arrow) height is at the same level as the superior aspect of the LMCA. Computed tomography transverse plane view at (C, D) TAVR commissure/leaflet level and (E, F) LMCA ostial level. Notice the juxtaposition of the commissural posts (green circles) and the LMCA (red outline). IVUS images of the LMCA minimum lumen (G) after predilation with a 2.5 mm balloon (H) after IVL and (I) after multistenting. Notice the calcium fractures after IVL; the white arrows demarcate the edges of fractured calcium. AVR, aortic valve replacement; IVL, intravascular lithotripsy; IVUS, intravascular ultrasound; LMCA, left main coronary artery; TAVR, transcatheter aortic valve replacement. [Color figure can be viewed at wileyonlinelibrary.com]
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A coronary computed tomography angiography showed a calcified aortic valve leaflet pinned up in the sinus of Valsalva by the TAVR struts, causing stenosis of the LMCA ostium (Figure 2A-F). Information: Video 2). Intravascular ultrasound (IVUS; Eagle eye platinum ST; Philips) evaluation was performed, which confirmed a substantial lumen gain (minimum luminal area increased from 4.1 mm2 after the first predilation to 11.8 mm2 after multistenting) after PCI. (Figure 2G-I and Supporting Information: Videos 3-5. NB: as the IVUS jumped from the narrowest part before stenting, the minimum lumen in 2G is probably overestimated.) Moreover, IVUS exemplified calcium fracturing after IVL as the mechanism underlying the effect of IVL (Figure 2H and Supporting Information: Video 4).