Delayed Coronary Obstruction After TAVR: A Complication We Had Not Considered

Delayed coronary obstruction (after TAVR, outside the cath lab) is a rare complication with high mortality rates, not unlike acute obstruction. Cardiologists should be expectant and, upon the slightest suspicion of this complication, patients should be brought back to the cath lab for a coronary angiography.

Occlusion immediately after implant release has been well-studied and described (risk factors, prevention techniques, more akin devices, etc.), but we ignored that this event can take place even months after the procedure.

Data for this work were retrospectively collected from an international multicenter registry between 2005 and 2016.

During the study period, 38 delayed coronary obstructions (incidence 0.22%) were observed after TAVR from a total of 17,092 patients. Occlusions were more common after valve-in-valve procedures (0.89% vs. 0.18%; p < 0.001) and in cases in which self-expandable valves were used during the index procedure (0.36% vs. 0.11% for balloon-expandable; p < 0.01).

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Delayed occlusion was most frequent within 24 hours from the procedure (47.4%; n = 18); 6 (15.8%) cases occurred between 24 hours and 7 days, and the remaining 14 (36.8%) occurred within 60 days.

The most frequent presentation was cardiac arrest (31.6%), followed by ST-segment elevation myocardial infarction (23.7%; n = 9). The left coronary artery was the culprit vessel in most cases (92.1%).

Stent implantation in this registry was successful in about 70% of all patients, thus indicating that angioplasty should be attempted whenever possible.

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In-hospital mortality reached 50% and was higher among patients who experienced the event within 7 days from the index procedure (62.5% vs. 28.6%; p = 0.09).

Conclusion

Delayed coronary occlusion following TAVR is a rare phenomenon with an extremely high mortality rate. Angioplasty should be attempted whenever possible, since stent implantation was successful in about 70% of all cases.

Original title: Delayed Coronary Obstruction After Transcatheter Aortic Valve Replacement.

Reference: Richard J. Jabbour et al. J Am Coll Cardiol 2018;71:1513-24.

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