抄録
Although transcatheter aortic valve replacement (TAVR) is widely used, it remains challenging for patients with severe aortic stenosis (AS) concomitant with coronary artery disease (CAD). The guidelines recommend percutaneous coronary intervention (PCI) prior to TAVR only if the left main (LM) or the proximal left anterior descending (LAD) artery is extensively occluded. However, the priority order of these interventions (i.e. PCI and TAVR) remains undefined in AS patients with severe stenosis of other epicardial arteries. In this paper, we reported two representative AS patients complicated with severe stenosis in the middle part of the right coronary artery (RCA). One patient had entered hemodynamic collapse immediately after plain old balloon angioplasty for the culprit lesion where a vulnerable plaque existed. In the other patient with AS, non-ST-elevated myocardial infarction (NSTEMI) occurred after TAVR in the middle part of the RCA, which was treated conservatively. These two cases suggest that the essential indication for revascularization should be limited to the LM lesion and proximal LAD only, as recommended in the guidelines. However, if coronary artery access after TAVR is anatomically complex and difficult, and if the coronary supply is large enough to affect hemodynamics, PCI prior to TAVR should be considered. During PCI, maximum effort should be made to examine vulnerable plaques with imaging devices, reduce the risk of slow flow with distal protection, and prepare for temporary mechanical circulatory support.
