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DOI: 10.1055/s-0029-1248002
Consideration of the feasibility of transcatheter aortic valve implantation using cardiac computed tomography – Case report of a patient with severe aortic stenosis and undiagnosed coronary anomaly
Introduction: The present case demonstrates the pre-interventional consideration of transcatheter aortic valve implantation (TAVI) in a high-risk patient with severe aortic stenosis (AS) and concomitant single coronary artery arising from the right coronary sinus of Valsalva. Case report: A 90-year-old woman with severe AS was send to our department to evaluate the possibility of TAVI. She suffered from recurrent left ventricular decompensation and dyspnoe NYHA III. Due to several co-morbidities the surgical risk was deemed excessive by a cardiologist and cardiac surgeon. Pre-interventionally, a contrast-enhanced multi-slice cardiac computed tomography (MSCT) was performed as part of the regular TAVI screening process for evaluation of the so-called device „landing zone“ (DLZ). Using multiplanar reconstruction the aortic annulus size was 22.5mm and a massive, symmetric calcification of the DLZ was observed. Besides, a concomitant single coronary artery arising from the right coronary sinus of Valsalva was detected (fig.1). The left main artery showed an anterior course in front of the right ventricular outflow tract (fig.2), which is known to be a benign form of coronary anomalies. (1) The case was discussed interdisciplinary. The anatomical conditions of the size and anatomy of the DLZ was adjudged to be possible for a `small´ (26mm) CoreValve prosthesis®. Due to excessive DLZ calcification with the risk of ostial occlusion due to a potential shift of a calcification plaque (fig.3) caused by the prosthesis, we refrained from performing TAVI and only performed valvuloplasty using a 20/60mm TYSHAK® balloon. This lead to a significant clinical improvement and a reduction of the peak pressure gradient from 104 to 40 mmHg. No myocardial infarction occurred peri- and post-procedurally. Conclusion: Consideration of the appropriate procedure in high-risk patients with AS requires different imaging modalities including cardiac MSCT for exact anatomical evaluation.
Figure 1: Example of multiplanar reconstruction (coronal [top left], single oblique sagittal [top right] and double oblique transversal view [down left]) for semi-quantitative evaluation of calcification in the CoreValve device `landing zone´ (DLZ). A massive, symmetric calcification of the DLZ was observed. Besides, a concomitant single coronary artery arising from the right coronary sinus of Valsalva was detected.
Figure 2: Advanced Vessel Analysis: A concomitant single coronary artery arising from the right coronary sinus of Valsalva was detected The left main coronary artery showed an anterior course in front of the right ventricular outflow tract (benign form of coronary anomalies).
Figure 3: Multiplanar reconstruction, single oblique sagittal view: Massive DLZ calcification with the risk of potential ostial occlusion due to a potential shift of calcification near the ostium of the single coronary artery.
Literatur: [1] Kimbris D, Iskandrian AS, Segal BL, et al. Anomalous aortic origin of coronary arteries. Circulation 1974;58:606–15.
Aortic valve calcification - Aortic valve stenosis - Coronary anomaly - Device landing zone - Multi-slice computed tomography - Transcatheter aortic valve implantation