Iatrogenic bidirectional dissection during transcatheter aortic valve implantation: a fatal complication

Iatrogenic aortic or coronary dissections are well known complications in the field of interventional cardiology. They are the most dreadful situations, often with terrible consequences. We present herein a case of bidirectional dissection to the right coronary artery and to the ascending aorta during a transcatheter aortic valve implantation procedure.

Iatrogenic bidirectional dissection of the right coronary artery and the ascending aorta: the worst nightmare for an interventional cardiologist

Although rare, iatrogenic aortocoronary dissection is one of the complications most dreaded by the interventional cardiologist. If not managed promptly, it can have redoubted and serious consequences. Herein, we present the case of a 70 year-old woman who was treated by stenting of the second segment of the right coronary artery (RCA) for recurrent angina but, unfortunately, the procedure was complicated by anterograde dissection of the RCA with a simultaneous retrograde propagation to the proximal part of the ascending aorta. Successful stenting of the entry point was able to recuperate the RCA and to limit the retrograde propagation to the ascending aorta, but there was an extension of the dissection to the aortic valve leaflets resulting in a massive aortic insufficiency. Therefore, an isolated surgical aortic valve replacement was performed.

Procedural results and 30-day clinical events analysis following Edwards transcatheter aortic valve implantation in 48 consecutive patients: initial experience

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is a rapidly evolving strategy for therapy of aortic stenosis. We presented the procedural results and analyzed the death causes of 30-day mortality and clinical events in patients who underwent TAVI with Edwards prosthetic valves in University Hospital of Caen, France.

METHODS

The patients with severe aortic stenosis but at high surgical risk or inoperable were considered as candidates for TAVI. Forty-eight patients undergoing TAVI from July 2010 to September 2011 were enrolled in this registry. The Edwards prosthetic valves were solely used in this clinical trial.

RESULTS

Overall 48 patients underwent TAVI, 28 of which accepted TAVI by trans-femoral (TF) approaches, 20 by trans-apical approaches (TA). The aortic valve area (AVA) was (0.70 ± 0.23) cm(2), left ventricular ejection fraction (LVEF) was (57.4 ± 17.6)%, Log EuroSCORE was (19.2 ± 15.8)%, mean gradient was (47.0 ± 16.6) mmHg. There were no significant differences between TF and TA groups in all these baseline parameters. Device success rate was 95.8%, and procedural success rate was 93.7% in total. Procedural mortality was 6.7% (3/48): two deaths in TA group (10%), and one death in TF group (3.6%). Forty-six Edwards valves were implanted: 10 Edwards Sapien and 36 Edwards XT. Procedure-related complications included cardiac tamponade in 2 cases (4.2%), acute myocardial infarction (AMI) in 1 case (2.1%), permanent pacemaker implantation in 1 case (2.1%), life-threatening and major bleeding in 3 cases; access site related major complication in 1 case, AKI stage 3 in 3 cases (6.3%), minor stroke in 1 case (2.1%). Thirty-day survival rate was 89.6%. There were 5 deaths in total (10.4%): 4 in TA group (20%) and 1 in TF group (3.6%).

CONCLUSION

The procedural success rate and 30-day mortality were acceptable in these high risk patients with Edwards prosthetic valves in the first 48 TAVI.

Spontaneous coronary artery dissection: one entity with several therapeutic options

Spontaneous coronary artery dissection is an unusual and a rare cause of acute coronary syndrome and sudden death with multiple predisposing factors. Prompt recognition is crucial for appropriate patient management, but specific guidelines for optimal treatment are lacking. We report four cases of women with spontaneous coronary artery dissection revealed by ST-segment elevation, three in women during postpartum and one case associated with a Marfan syndrome. Our cases span the different therapeutic options from medical treatment, stenting, to coronary artery bypass graft surgery.

Coronary-Pulmonary Fistulas Involving All Three Major Coronary Arteries Co-Existing With Myocardial Infarction

We report the case of a man who presented with acute anterior myocardial infarction and in whom the coronary angiogram showed tight stenosis of the left anterior descending coronary artery and the right coronary artery associated with substantial coronary-pulmonary fistulas involving all three major coronary arteries. We discuss the possible links between coronary artery fistulas and myocardial infarction.

A rare combination of coronary anomalies: what is the culprit?

The case of a woman with anomalous origin of the circumflex coronary artery that communicates with the left ventricle via a fistula, revealed by typical angina, is described and the several pathomechanisms involved are discussed.

Successful medical management of a huge left main thrombus with bilateral coronary embolization

We report the case of a patient with a huge nonocclusive left main thrombus without underlying angiographic coronary lesion associated with bilateral coronary embolization, which was successfully and exclusively medically treated.

Downsizing from 6-French to 5-French guiding catheter after transradial coronary rotational atherectomy: a way to cross resistant calcified lesions

Some severe calcified coronary lesions may resist the advancement of the stent despite rotational atherectomy and balloon predilation, when used via the transradial approach due to a lack of support of the guiding catheter and may require switching to the femoral approach. The latter is known to have better support but with the increased risk of vascular access site complications. Deep engagement of the guiding catheter with preferring 5-French to 6-French to avoid coronary dissection provides an active support and may be a solution in such situations. We report two cases of patients with calcified coronary lesions, where rotational atherectomy and balloon predilation were not sufficient for the stent to cross the lesion and switching to 5-French guiding catheter allowing a safe deep engagement which was the solution using the transradial access.

Tako-Tsubo Cardiomyopathy Triggered by Misdirection

Tako-Tsubo cardiomyopathy (TTC), also known as transient left ventricular apical ballooning syndrome or stress-induced cardiomyopathy, is a novel reversible cardiomyopathy mimicking acute myocardial infarction without epicardial coronary artery disease. The exact physiopathology of TTC remains unclear. It is usually precipitated by acute physical or emotional stress and it most commonly affects postmenopausal women. The growing number of clinical cases of TTC have demonstrated a wide field of possible etiologies beyond the emotional stress. We report a case of a 67-year-old postmenopausal woman who was being supplemented by enteral feeding via a nasogastric tube and who developed TTC due to misdirection, probably favored by the mechanical blockade by the nasogastric tube, while swallowing the drug pills.