Multimodality Imaging for Facilitating Percutaneous Coronary Intervention of a Calcified Nodule Post Redo TAVR

Figures

• 

  Figure 1. Transthoracic Echocardiography of Redo Transcatheter Aortic Valve Replacement (A) A 2-dimensional (2D) apical 5-chamber view demonstrates the left ventricular outflow tract and the aortic valve (AV), with the previous transcatheter heart valves appearing as echogenic structures. (B) Doppler imaging across the aortic valve confirms proper function of the previous transcatheter heart valves, with no evidence of stenosis or regurgitation. The recorded peak velocity is 187 cm/s, the mean pressure gradient (PG) is 7 mm Hg, and the velocity-time integral (VTI) is 36.0 cm.

• 

  Figure 2. Nonselective Left Coronary Angiography Cardiac catheterization showing the frame of both transcatheter aortic valve implants: the outer SAPIEN 3 valve (Edwards Lifesciences), and the inner Evolut PRO valve (Medtronic). Nonselective left main artery engagement resulting in angiographic ambiguity for severity of stenosis of the ostial left main artery and marginal branch.

• 

  Figure 3. Multidetector Computed Tomography Morphologic Features (A) Parasagittal multidetector computed tomography imaging illustrates the spatial relationship between the previously implanted transcatheter heart valves and the coronary origins. The SAPIEN valve (Edwards Lifesciences) is depicted as the larger outer stent, and the inner Evolut PRO valve (Medtronic) is nested within the SAPIEN, with minimal separation between the 2 valves. The left coronary artery (asterisk) originates above the upper boundary of the SAPIEN metallic frame (arrowheads) at the midlevel of the fourth Evolut cell frame. The neoskirt plane (NSP) of the SAPIEN valve (dashed yellow line) is identified below the coronary risk plane (CRP) of the left coronary artery (dashed red line). The yellow dot marks the contracted leaflets of the SAPIEN valve. (B) Multidetector computed tomography axial angulation demonstrating that the LCA originates within a free cell space (arrowheads). Ao = aorta; LCA = left coronary artery; LV = left ventricle.

• 

  Figure 4. Multidetector Computed Tomography–Driven Measurements (A) The Evolut PRO (Medtronic)–to-aorta distance is 2.5 mm, the Evolut PRO–to-coronary distance is 2.8 mm, (B) the commissural-coronary angle measures 24.8° (arrowheads highlight the neocommissures), (C) the sinotubular junction width is 24.4mm, and (D) the valve-to-sinotubular junction (VTSTJ) distance is 1.5 mm. VTA = valve to aorta; VTC = valve to coronary.

• 

  Figure 5. Multidetector Computed Tomography Planning for Guiding Catheter Selection (A) Multidetector computed tomography simulation of the guiding catheter shows the recreated catheter’s tip (yellow curve) positioned 2.9 cm from the greater curvature of the aortic wall adjacent to the left main artery origin, proposing an extra backup (EBU) 3.0 guiding catheter as the optimal choice for selective coronary engagement. (B) Fluoroscopic imaging demonstrates the EBU 3.0 catheter, selected on the basis of multidetector computed tomography measurements, successfully engaging the left coronary artery. Abbreviations as in Figure 3.

• 

  Figure 6. Left Coronary Artery Revascularization (A) Fluoroscopic imaging depicts stent positioning at the left coronary artery ostium in relation to the transcatheter valve prostheses. (B) Poststent deployment angiography confirms restored coronary flow and resolved stenosis, with the deployed stent maintaining left coronary artery patency. The images emphasize the challenges of percutaneous coronary intervention in this setting and the importance of precise stent positioning with multimodal guidance.

• 

  Figure 7. Sequential Intravascular Ultrasound Imaging of Left Main Artery (A) Intravascular ultrasound image demonstrates a patent stent in the left main artery. (B to F) Sequential intravascular ultrasound images reveal an uncovered proximal left main segment with an eccentric calcified nodule protruding into the vessel lumen and causing significant stenosis.

• 

  Figure 8. Intravascular Ultrasound-Guided Left Main Artery Stenting (A) Intravascular ultrasound image of left main artery stent with a measurement of 4.2 mm × 4.6 mm, guided post-dilatation by a 5-mm noncompliant balloon. (B to F) Sequential intravascular ultrasound images post-stent optimization reveal good stent expansion and proper apposition of left main artery stent.

• 

  Visual Summary. Sequential Multimodality Imaging in the Management of Complex Lesion Leading to Successful Revascularization AO = aorta; EBU = extra backup; IVUS = intravascular ultrasound; LM = left main; LV = left ventricle; MDCT = multidetector computed tomography; NSTEMI = non–ST-segment elevation myocardial infarction; PCI = percutaneous coronary intervention; TAVR = transcatheter aortic valve replacement.