An 84-year-old man presented with dyspnea NYHA III and was referred to our institution for the treatment of severe aortic stenosis. He had chronic kidney disease, prior stroke, and paroxysmal atrial fibrillation. Coronary angiography showed significant stenosis in right coronary artery. Our strategy was to perform TAVR for severe aortic stenosis and PCI for coronary artery disease with minimum contrast volume. At first, he underwent successful TAVR without worsened kidney function.
Blood test: Hemoglobine 10.6 g/dl, creatine 2.01 mg/dl, estimate glomerular filtration rate 25.3 ml/min/1.73m2.
ECG: sinus rhythm, heart rate 68 bpm, no ST-T change.
CXR: heart enlargement (-), pleural effusion (-), congestion (-).
TTE: LVEF 77％, IVSTd 11 mm, PWTd 11 mm, LVDd 41 mm, LVDs 22 mm, no asynergy, trivial mitral regurgitation, trivial tricuspid regurgitation, aortic valve (post TAVR): peak velocity 1.83 m/sec, mean pressure gradient 8 mmHg, trivial paravalvular leakage.
Coronary angiography: diffuse moderate stenosis in LAD, diffuse severe stenosis in LCX, diffuse severe stenosis in RCA mid.
Fractional flow reserve to LAD (post TAVR): 0.81
LCX has a small area of return to the myocardium
Therefore, heart team decided to perform PCI for RCA and to do careful follow-up in LCX and LAD with optical medical therapy.