Unexpected Coronary Artery Malperfusion during Trans-Apical Transcatheter Aortic Valve Replacement

Objective: Trans-apical (TA)-transcatheter aortic valve replacement (TAVR) is one of the alternative approaches in cases with poor femoral or iliac access. We have previously reported that placing a wound retractor (WR) into the pericardium provides good surgical exposure in TA-TAVR. In this case, we experienced an unexpected iatrogenic coronary obstruction due to WR. Case Presentation: An 84-year-old man presented with symptomatic severe aortic stenosis. He had a dilated left ventricle, with proximity of the apex to the chest wall. A small WR was placed in the pericardial cavity to expose the apex. We mobilized the apex by placing gauzes in the pericardial space. We delivered the balloon expandable transcatheter heart valve under rapid ventricular pacing. Severe hypotension was sustained, and echocardiography revealed hypokinesis of the anterolateral wall. After removing the gauze from the pericardial cavity, the systolic blood pressure increased slightly. We performed coronary angiography to rule out coronary obstruction, which showed obstructions in the left anterior descending artery and diagonal branch. We suspected multiple coronary embolizations; we therefore removed the WR to obtain a clearer angiogram. A repeat angiogram showed no coronary obstruction. Then, we realized that the coronary arteries were obstructed by the ring of WR and that obstruction was exacerbated by gauzes placed in the pericardial space. Conclusion: Although placing a WR into the pericardial cavity can facilitate the procedure, careful attention should be paid to avoid coronary obstruction in patients in the proximity of the heart to the chest wall.