Percutaneous Pulmonary Valve Implantation Contraindicated by Severe Aortic Regurgitation Due to Left Coronary Sinus Deformation

A 32-year-old man had undergone a Ross procedure involving implantation of a 26-mm pulmonary homograft at the age of 20 due to severe aortic regurgitation (AR) caused by rheumatic disease. He came to our attention due to progressive calcification of the graft causing a systolic maximum gradient of 67 mmHg with a hypertrophic right ventricle (RV) on echocardiography. Percutaneous pulmonary valve implantation (PPVI) was proposed. Basal RV outflow tract angiography confirmed the known graft stenosis, and aortic basal and 3-D rotational angiography showed no significant AR (Figure A,C). Aortography was then repeated with a Cristal balloon 23×45 mm (Balt Extrusion, Montmorency, France) inflated inside the homograft. Severe AR (Figure B) was seen on aortography due to compression and deformation of the left coronary sinus (Figure D; white arrow). PPVI was thus contraindicated and the patient underwent surgery.

Figure.

Imaging during attempted percutaneous pulmonary valve implantation. (A) No significant aortic regurgitation was seen, as confirmed on (C) 3-D rotational angiography. (B) Severe aortic regurgitation after balloon inflation inside the pulmonary homograft. (D) Compression and deformation of the left coronary sinus (white arrow).

Coronary artery compression during balloon testing is the main contraindication to PPVI.¹ The occurrence of significant AR is uncommon.² 3-D rotational angiography can clearly show the latter mechanism during attempted PPVI.

Disclosures

The authors declare no conflicts of interest.

References

• 1.   Morray BH, McElhinney DB, Cheatham JP, Zahn EM, Berman DP, Sullivan PM, et al. Risk of coronary artery compression among patients referred for transcatheter pulmonary valve implantation: A multicenter experience. Circ Cardiovasc Interv 2013; 6: 535–542.
• 2.   Lindsay I, Aboulhosn J, Salem M, Levi D. Aortic root compression during transcatheter pulmonary valve replacement. Catheter Cardiovasc Interv 2016; 88: 814–821.