2905780

An 85-year-old woman presented with intermittent chest tightness and dyspnea for 6 months. She had hypertension,diabetes mellitus, paroxysmal atrial fibrillation and end-stage renal disease under regular hemodialysis. The physical examination revealed high-pitched,crescendo-decrescendo, mid-systolic murmur.

A transthoracic echocardiography revealed normal systolic function (LVEF=72%), concentric left ventricular hypertrophy without intraventricular pressure gradient and severe aortic calcification and stenosis(Vmax=356 cm/s, Mean PG=30 mmHg, AVA=0.92 cm²). 

PSAX.avi

1^stinterventionnonsignificant stenosis lesions at ostial and middle left anterior descending artery and distal left circumflex artery.Severe aortic stenosis
2^nd interventionThe LAD ostial lesion was evaluated by IVUS, which showed large plaque burden with minimal luminal area of 3.0 mm²
CAG1.avi
CAG1_2.avi

1^stintervention1.    Diagnosticcoronary angiography showed nonsignificant stenosis lesions at ostial and middle left anterior descending artery and distal left circumflex artery.2.    The guidewire was changed to Amplatz super stiff 260 and an Evolut R 26mm self-expandable valve was implanted smoothly. 3.    There was mild paravalvular leakage and mild pressure gradient between Ao and LV. Bilateral femoral wounds were closed by Abbott's Perclose ProGlide™ and St.JudeAngio-Seal Closure Device.
2^ndintervention (7 months later, due to persistent chest pain)1.    The LAD ostial lesion was evaluated by IVUS, which showed large plaque burden with minimal luminal area of 3.0 mm² 2.    Angioplasty with“Sapphire II 3.0 mm* 15mm” to ostial LAD and “Sapphire II NC 4.0 mm* 15mm” to distalLM. 3.    Kissing balloon technique to LM bifurcation with “Hiryu NC 3.5 mm* 15 mm” to LAD and “SapphireII 3.0 mm* 15mm” to LCx4.    Angioplasty with “NC Sapphire 4.0 mm* 15 mm” to distal LM5.    Deployed “Synergy 3.0 mm* 38 mm” to LM-LAD
Refractory chest pain was still complained after intervention. A transthoracic echocardiography revealed significant left ventricular outflow tract obstruction (pressure gradient increased to 63 mmHg),which was not found on the pre-operative evaluation. After bisoprolol/diltiazem administration and right ventricular pacing with permanent pacemaker (DDDR), the pressure gradient decreased to 9 mmHg and her chest pain resolved.
TAVI.avi


TTE after TAVI and PCI.png


TTE 5 years prior to TAVI (mild AS only).png

In elderly patients with severe aortic stenosis, hypertrophic cardiomyopathy was occasionally found to coexist. Even though TAVI significantly relieves transaortic pressure gradient caused by aortic stenosis, TAVI may worsen left ventricular outflow obstruction caused by hypertrophic cardiomyopathy. Therefore, the evaluation before TAVI should include the LVmyocardium, while the hemodynamic consequence after TAVI procedures should be assessed. Treatment targeting both aortic stenosis and LV outflow obstruction should be thoroughly evaluated before the intervention in all patients.