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Severe aortic valve and ostial coronary disease - when it rains, it pours!
Session:
Sessão Speaker’s Corner - Casos clínicos desafiantes… em Cardiologia de Intervenção
Speaker:
Diogo Santos Ferreira
Congress:
CPC 2022
Topic:
H. Interventional Cardiology and Cardiovascular Surgery
Theme:
25. Interventional Cardiology
Subtheme:
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Session Type:
Sessão de Casos Clínicos
FP Number:
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Authors:
Diogo Santos Ferreira; Mariana Brandão; Cláudio Guerreiro; Marisa Silva; Gustavo Pires de Morais; Lino Santos; Alberto Rodrigues; Daniel Martins; Nelson Paulo; Fátima Neves; Adelaide Dias; Daniel Caeiro; Pedro Braga; Bruno Melica; Ricardo Fontes-Carvalho
Abstract
<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">A 47-year-old male is referred to Cardiology Consultation. His past medical history revealed a previous Hodgkin Lymphoma, having been subjected to radiotherapy, chemotherapy and splenectomy during his childhood.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">He complained of tiredness and dyspnea for moderate efforts over the previous weeks, and a grade III/VI systolic murmur was evident on cardiac auscultation. Echocardiogram denoted moderate to severe aortic stenosis and insufficiency, with preserved ejection fraction. Coronarioraphy showed left main ostial disease. Over follow-up, he developed severe SARS-COV2 pneumonia, with need of invasive ventilation, showing good recovery and was discharged home with no sequelae.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">Echocardiogram was repeated afterwards (video 1), showing de novo depression of systolic function (ejection fraction of 40%) with diffuse hypokinesia, alongside a severe aortic valve calcification, mean transvalvular gradient of 38mmHg, valvular area of 0.6cm<sup>2</sup>, and moderate regurgitation. Coronariography (video 2) was repeated, with worsening left main ostial disease (90%), alongside 80% ostial right coronary stenosis. Having developed de novo atrial flutter with rapid ventricular response and acute pulmonary edema, he was stabilized in the cardiac intensive coronary unit through chemical cardioversion to sinus rhythm. Cardiac computed tomography confirmed extensive calcification of aortic valve, extending to both coronary ostia, root and ascending aorta (image 1).</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">This case of severe aortic valve and ostial coronary disease was discussed in Heart Team, but existing porcelain aorta ruled out the possibility of a combined surgical aortic valve replacement and coronary artery bypass graft (CABG). It was decided to use a hybrid approach, to first perform transcatheter aortic valve implantation (TAVI), followed by CABG.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">An Edwards SAPIEN 3 Ultra 26mm, delivered under pacing over the right femoral artery, was implanted (video 3), with a good final result and no rhythm disturbances. Twenty-one days later, CABG was performed, with a complete revascularization through triple bypass without extracorporeal circulation, from left internal mammary artery (IMA) to left anterior descending artery, left to right IMA to obtuse marginal in a Y configuration, and right IMA stump to right saphenous venous graft to right coronary artery.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">The post-operative period was uneventful, and the patient was discharged 4 days later. He exhibited a marked clinical improvement over follow-up, with recovery of ejection fraction to 55%.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">This case underlines that cancer therapy-induced cardiomyopathy may present in complex settings, requiring individualized treatment plans. Hybrid approaches are increasingly attractive solutions for these challenging clinical scenarios, hence the importance of Heart Team discussions.</span></span></p>
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