BAV and Calcified Undilatable High Risk PCI – February 2018
77 year old male with known severe aortic stenosis, presented with NYHA and CCS Class III angina and dyspnea and a positive pharmacological MPI for inferior wall ischemia. A Cardiac Cath on December 18, 2017 revealed 3 V CAD: 95% calcified ostial RCA, 70% distal LAD, 70% diagonal, 60% proximal LCx with SYNTAX Score of 18 and LVEF 60%. Echo revealed mean aortic gradient of 55mmHg with AVA of 0.6 cm2. Heart Team discussion recommended PCI of RCA followed by TAVR after one month. Patient underwent rotational atherectomy (using 1.5, 1.75 and 2.15mm burrs) of the RCA ostial lesion followed by high pressure balloon dilatation, but ostial lesion could not expand, still 80% residual lesion. Patient is now planned for first the BAV and then high risk PCI using larger rota burr atherectomy followed by DES and Ostial Flash balloon inflation for ostial stent optimization.
QWhile doing structural valve cases with concomitant CAD, please share your best three tips?
A.Three important tips for the Interventional management of combined coronary and aortic valve disease are; 1) If BAV+PCI needs to be done at the same sitting, then do BAV first followed by PCI, 2) Stage the TAVR after 30-days of PCI and 3) Try to use Sapien TAVR valve which has ease of coronary access in these CAD pts, if restenosis occurs in future.
QAre there cases with planned TAVR where you would proceed with PCI?
A.Coronary angiography is routinely done pre-TAVR and 20-25% of these pts have severe stenosis in major epicardium vessel which need to be treated pre-TAVR. These pts get the PCI first and then planned TAVR after 1 month. Rarely simple PCIs and TAVR can also be done in the same sitting; we have done 12pts with PCI+TAVR at the same sitting.
QIs there an absolute cutoff for mean gradient or AVA where you will always perform balloon valvuloplasty?
A.There is no reported absolute cutoff of the mean aortic gradient where BAV should be done before PCI. But we strongly recommend BAV first, if mean gradient is >50 mmHg or PV >5M/sec as in these cases wait of 1-2 months could be troublesome. Now a days most of the TAVR (>95%) are done without prior BAV.
QWhy not TAVR instead of valvuloplasty ahead of PCI?
A.Since coronary engagement could be difficult post TAVR, PCI should always be done ahead of TAVR. BAV can be done as a bridge if there is urgency in treating the aortic stenosis; this has been incorporated in the latest Structural Heart Intervention guidelines.
QDoes it matter whether lesion is located in RCA or LCA in cases with concomitant severe AS and pending TAVR?
A.Yes as a general rule, PCI of RCA or Left system should be done before the TAVR because potential issues with coronay engagement post TAVR. Clearly, PCI if needed, can safely be done post TAVR.
QIn your case today, what was your big apprehension for performing balloon valvuloplasty?
A.In our case there was moderate AI and mean aortic gradient was barely 30mmHg; both these points will deter us from doing BAV, as it will not be clinically needed in a pt who is going to get TAVR after few months.
QWhile using ostial flash balloon, are there cases you will not consider?
A.Ostial flash balloon should not be used if there is no protrusion of stent struts outside the ostium or there is dye staining at the coronary sinus signifying ostial or aortic wall dissection.
QWhat seem to be the advantages of the Wolverine over Flextome?
A.Wolverine cutting balloon has been made more flexible by shortening the height of the foot plate on which cutting blades are mounted. Hence crossing profile of Wolverine is lower then Flextome.
QIs there a situation where you would prefer the chocolate balloon over cutting balloons?
A.Both cutting and chocolate balloons work by similar mechanism of scoring the inelastic plaque and hence no preference of one vs other. Perhaps in dissection after PTCA, if lesion did not open, chocolate balloon may be preferred over cutting balloon. My personal experience has shown that cutting balloon does better job of scoring the plaque compared to chocolate balloon or Angiosculpt.
QWhat are the plans for addressing aortic disease in today's patient?
A.This pt has completed all the TAVR work up and has been scheduled to undergo Sapien TAVR in early April.