SHARE @ Advocate Health - Midwest - Scientific Day: A Delayed Presentation of Coronary Artery Dissection After Transcatheter Aortic Valve Replacement
 

Affiliations

Advocate Lutheran General Hospital

Abstract

Introduction/Background:

Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of severe aortic stenosis, especially in high-risk patients. Despite its minimally invasive nature, TAVR carries risks, including conduction abnormalities, vascular injury, and coronary obstruction. Left main (LM) coronary artery dissection is a rare but life-threatening complication. This case highlights a delayed LM dissection post-TAVR, requiring emergent coronary artery bypass grafting (CABG) and venoarterial extracorporeal membrane oxygenation (VA-ECMO).

Description:

A 79-year-old female with hypertension, hyperlipidemia, antiphospholipid syndrome on warfarin, and bilateral carotid artery stenosis underwent TAVR for symptomatic aortic stenosis. Preprocedural catheterization showed non-obstructive coronary disease. The procedure was complicated by transient complete heart block, requiring transvenous pacing. Postoperatively, she had a peri-arrest event with hypotension and bradycardia, responding to atropine and pressors. Electrocardiogram (ECG) revealed a new left bundle branch block and first-degree AV block, prompting implantation of a Micra pacemaker. Four days post-TAVR, she developed acute chest pain, dyspnea, and troponin >16K ng/L. Echocardiography showed ejection fraction (EF) 20% with regional wall motion abnormalities. Angiography revealed LM dissection extending from the aorta. Percutaneous intervention was unsuccessful due to hemodynamic instability, necessitating emergency CABG. Intraoperatively, she developed cardiogenic shock with EF 5%, requiring VA-ECMO. She was transferred to the ICU with an open chest on VA-ECMO and vasopressors. Over two days, she stabilized, allowing ECMO weaning and decannulation. Postoperative complications included cardiogenic shock, acute kidney injury requiring dialysis, and severe malnutrition. Despite challenges, she engaged in rehabilitation and was transferred to a long-term acute care facility.

Discussion:

Coronary dissection post-TAVR is rare and usually occurs intraoperatively. Delayed presentation, as seen here, is uncommon and complicates diagnosis. Potential mechanisms include guidewire or catheter trauma and altered coronary flow dynamics. Prompt recognition of ischemic symptoms and emergent intervention are critical. This case underscores the importance of vigilance, timely imaging, and a multidisciplinary approach to improving outcomes despite severe complications.

Presentation Notes

Presented at Scientific Day; May 21, 2025; Park Ridge, IL.

Full Text of Presentation

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Document Type

Poster


 

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May 21st, 11:41 AM May 21st, 1:15 PM

A Delayed Presentation of Coronary Artery Dissection After Transcatheter Aortic Valve Replacement

Introduction/Background:

Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of severe aortic stenosis, especially in high-risk patients. Despite its minimally invasive nature, TAVR carries risks, including conduction abnormalities, vascular injury, and coronary obstruction. Left main (LM) coronary artery dissection is a rare but life-threatening complication. This case highlights a delayed LM dissection post-TAVR, requiring emergent coronary artery bypass grafting (CABG) and venoarterial extracorporeal membrane oxygenation (VA-ECMO).

Description:

A 79-year-old female with hypertension, hyperlipidemia, antiphospholipid syndrome on warfarin, and bilateral carotid artery stenosis underwent TAVR for symptomatic aortic stenosis. Preprocedural catheterization showed non-obstructive coronary disease. The procedure was complicated by transient complete heart block, requiring transvenous pacing. Postoperatively, she had a peri-arrest event with hypotension and bradycardia, responding to atropine and pressors. Electrocardiogram (ECG) revealed a new left bundle branch block and first-degree AV block, prompting implantation of a Micra pacemaker. Four days post-TAVR, she developed acute chest pain, dyspnea, and troponin >16K ng/L. Echocardiography showed ejection fraction (EF) 20% with regional wall motion abnormalities. Angiography revealed LM dissection extending from the aorta. Percutaneous intervention was unsuccessful due to hemodynamic instability, necessitating emergency CABG. Intraoperatively, she developed cardiogenic shock with EF 5%, requiring VA-ECMO. She was transferred to the ICU with an open chest on VA-ECMO and vasopressors. Over two days, she stabilized, allowing ECMO weaning and decannulation. Postoperative complications included cardiogenic shock, acute kidney injury requiring dialysis, and severe malnutrition. Despite challenges, she engaged in rehabilitation and was transferred to a long-term acute care facility.

Discussion:

Coronary dissection post-TAVR is rare and usually occurs intraoperatively. Delayed presentation, as seen here, is uncommon and complicates diagnosis. Potential mechanisms include guidewire or catheter trauma and altered coronary flow dynamics. Prompt recognition of ischemic symptoms and emergent intervention are critical. This case underscores the importance of vigilance, timely imaging, and a multidisciplinary approach to improving outcomes despite severe complications.

 

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