2023 Volume 87 Issue 11 Pages 1706-
A 78-year-old man with a history of percutaneous coronary intervention (PCI) to the proximal left anterior descending artery (LAD) 12 years prior strongly preferred transcatheter aortic valve replacement (TAVR) to surgery for a mid-LAD calcified stenosis and severe aortic stenosis ([AS], mean AV pressure gradient, 70.0 mmHg; AV area, 0.66 cm2) (Figure A). After comprehensive discussion with the heart team, PCI and subsequent TAVR with a self-expandable valve were planned, considering coronary accessibility. Although combined orbital and subsequent rotational atherectomies achieved luminal enlargement, wire perforation occurred in the distal-LAD branch, and hemostasis was performed using coil embolization. Additional stent implantation and intra-aortic balloon pump support were performed to increase coronary flow (Figure B–D, Supplementary Movie). After the PCI, neither left ventricular (LV) wall motion asynergy nor pericardial effusion was observed on transthoracic echocardiography (TTE); however, a small periprocedural myocardial infarction occurred (peak creatinine kinase [CK, 524 U/L] and CK-myocardial band [88.6 ng/mL]), and TAVR was postponed. A week later, cardiopulmonary arrest suddenly occurred, and TTE during cardiopulmonary resuscitation showed cardiac tamponade (Figure E). Surgical hemostasis was performed because of refractory pericardial effusion suggestive of LV rupture. Intraoperative findings showed a pin-hole rupture of the infarcted myocardium (Figure F). Surgical hemostasis alone using a felt patch was difficult due to high intra-LV pressure caused by severe AS. Therefore, surgical AV replacement was concomitantly performed. The postoperative course was uneventful.
(A–D) Coronary angiograms. (A) No restenosis and severely calcified stenoses (white and yellow dotted lines, respectively); (B) coronary perforation in the distal left anterior descending (LAD) branch (arrowheads); (C) hemostasis via coil embolization (dotted arrowheads); and (D) final image. (E) Transthoracic echocardiogram shows massive pericardial effusion (arrows). (F) Intraoperative finding of a pin-hole rupture at the apical ventricle corresponding to the periprocedural myocardial infarct site (arrowheads).
Coil embolization for coronary perforation can cause iatrogenic myocardial infarction. This case demonstrated that high intra-LV pressure due to severe AS potentially facilitated LV rupture following a periprocedural myocardial infarction. In cases of high-risk PCI prior to TAVR, periprocedural myocardial infarction can cause catastrophic complications.
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Supplementary Movie. Angiography during percutaneous coronary intervention.
Please find supplementary file(s);
https://doi.org/10.1253/circj.CJ-23-0606
