Breitbart Philipp, Billig Hannah, André Florian, Frey Norbert, Korosoglou Grigorios
Department of Cardiology and Angiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Südring 15, 79189 Bad Krozingen, Germany.
Medical Department II, University Hospital Bonn, Bonn, Germany.
Eur Heart J Case Rep. 2024 Jun 12;8(6):ytae300. doi: 10.1093/ehjcr/ytae300. eCollection 2024 Jun.
Delayed coronary obstruction (DCO) is a rare but potentially life-threatening complication after transcatheter aortic valve implantation (TAVI) mostly affecting the left main coronary artery (LMCA) and often caused by prosthesis endothelialization or thrombus formations. Herein, we report an unusual case of a delayed LMCA-obstruction caused by a calcium nodule, which was diagnosed 4 months after TAVI due to recurrent ventricular tachycardia (VT) episodes.
A 73-year-old patient was readmitted to an external hospital with syncope three months after TAVI. Fast VT could be induced in electrophysiological examination, why the patient received a two-chamber implantable cardioverter defibrillator (ICD). However, after 1 month the patient was readmitted to our department with another syncope. Implantable cardioverter defibrillator records revealed multiple fast VT episodes (200-220 b.p.m.). In addition, the patient reported new-onset exertional dyspnoea (New York Class Association Stage III) and elevated high-sensitive cardiac troponin of 115 ng/L. Due to the symptoms and laboratory markers indicating potential myocardial ischaemia, a cardiac computed tomography angiography (CCTA) was performed. Cardiac computed tomography angiography revealed obstruction of the LMCA likely caused by calcium shift during TAVI. After CCTA-guided percutaneous coronary intervention, patient's course remained uneventful.
The present case report highlights the role of CCTA as a powerful non-invasive diagnostic tool in complex settings after TAVI. Delayed coronary obstruction as a procedural complication can occur after TAVI and manifest with various symptoms, including new-onset or recurrent VTs, like in the present case. Cardiac computed tomography angiography provided accurate assessment of the implanted prosthesis and detection of DCO, thus guiding the subsequent PCI.
延迟性冠状动脉阻塞（DCO）是经导管主动脉瓣植入术（TAVI）后一种罕见但可能危及生命的并发症，主要影响左主干冠状动脉（LMCA），通常由假体内皮化或血栓形成引起。在此，我们报告一例由钙结节导致的罕见延迟性左主干冠状动脉阻塞病例，该病例在TAVI术后4个月因反复室性心动过速（VT）发作而被诊断。
一名73岁患者在TAVI术后3个月因晕厥再次入住外院。在电生理检查中可诱发快速室性心动过速，因此患者接受了双腔植入式心律转复除颤器（ICD）。然而，1个月后患者因再次晕厥入住我科。植入式心律转复除颤器记录显示多次快速室性心动过速发作（200 - 220次/分钟）。此外，患者报告出现新发劳力性呼吸困难（纽约心脏协会心功能III级），高敏心肌肌钙蛋白升高至115 ng/L。由于症状和实验室指标提示可能存在心肌缺血，遂进行了心脏计算机断层扫描血管造影（CCTA）。心脏计算机断层扫描血管造影显示左主干冠状动脉阻塞，可能是TAVI期间钙移位所致。在CCTA引导下进行经皮冠状动脉介入治疗后，患者病情平稳。
本病例报告强调了CCTA作为TAVI术后复杂情况下强大的非侵入性诊断工具的作用。延迟性冠状动脉阻塞作为一种手术并发症可发生在TAVI术后，并表现为各种症状，包括新发或复发的室性心动过速，如本病例所示。心脏计算机断层扫描血管造影可对植入的假体进行准确评估并检测到延迟性冠状动脉阻塞，从而指导后续的经皮冠状动脉介入治疗（PCI）。
