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CASE20200924_011
High-Risk Intervention (diabetes, heart failure, renal failure, shock, etc) - High-Risk Intervention
Optical Coherence Tomography Guided Percutaneous Coronary Intervention Following Transcatheter Aortic Valve Replacement
Tatsuya Kamon1, Mizuki Miura2, Jiro Ando3, Kazutoshi Hirose3, Hiroki Shinohara3, Hiroyuki Kiriyama3, Akihito Saito3, Shun Minatsuki3, Hironobu Kikuchi3, Arihiro Kiyosue3, Satoshi Kodera3, Norifumi Takeda4, Issei Komuro3
The University of Tokyo, Japan1, University Hospital Zurich, Switzerland2, The University of Tokyo Hospital, Japan3, the University of Toikyo Hospital, Japan4,
[Clinical Information]
- Patient initials or identifier number:
T.N
-Relevant clinical history and physical exam:
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. 
-Relevant test results prior to catheterization:
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.
- Relevant catheterization findings:
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): 0.81LCX has a small area of return to the myocardiumTherefore, heart team decided to perform PCI for RCA and to do careful follow-up in LCX and LAD with optical medical therapy.
[Interventional Management]
- Procedural step:
Staged PCI to RCA was performed. The system was a left radial artery approach and 6Fr sheaths. A6Fr judkin’s right 4.0 was used to engage the RCA and coronary guidewire was advanced to distal RCA. To enhance backup, an extention catheter was inserted up to the proximal part of the RCA. Coronary artery imaging was performed using optical coherence tomography (OCT) with low-molecular-weight dextran without the use of contrast agents. The stenosis lesion was mainly calcification with partial ulceration, and the calcification was mild in thickness. Pre-dilation with 3.0 mm × 15 mm non-compliant balloon was performed, and OCT was performed again to confirm that calcification dissection was occurring. A 3.5 ×34 mm zotarolimus-eluting stent was deployed into RCA mid lesion and expanded at high pressure with 3.0 mm × 15 mm non-compliant balloon. The final OCT demonstrated good apposition and expansion of the stent. There was no vascular injury. A total of 15 ml of contrast agent use was minimal and the treatment was completed without complications. No contrast nephropathy was noted and the patient was discharged on the second postoperative day.
- Case Summary:
In this case, the patient underwent PCI with minimal contrast using low-molecular-weight dextran OCT as coronary imaging. The use of an extension catheter provided enhanced back-up and clearer images of OCT. OCT with low molecular weight dextran provides more information on vessel size, lesion length and plaque characteristics, which may lead to a reduction in contrast use.
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