JACC: CARDIOVASCULAR INTERVENTIONSVOL.

-, NO. -, 2020

ª 2020 PUBLISHED BY ELSEVIER ON BEHALF OF THE
AMERICAN COLLEGE OF CARDIOLOGY FOUNDATIONIMAGES IN INTERVENTION

Usefulness of Multislice Computed
Tomography in Percutaneous Coronary
Intervention Following Valve-in-Valve
Transcatheter Aortic Valve Replacement
Shiro Miura, MD, MSC,a Takehiro Yamashita, MD, PHD,a Naoki Iwakiri, MD,a Naoya Yoshida, CNMT,bYouhei Ohkawa, MD, PHDcAvalven 88-year-old man with anginal symptoms,

the closest aligned cell and interference by thereferred for percutaneous coronary inter-commissure, THV skirt, and CEP valve frame aroundvention

the left coronary artery ostium (Figures 1E to 1H,(PCI),transcatheter

hadaortic

undergone
valve

valve-in-replacement

Video 2) (1).

(TAVR) with 23-mm Evolut R transcatheter heart

Thereafter, we successfully performed PCI withvalve (THV) (Medtronic, Dublin, Ireland) 4 years

rotational atherectomy and drug-eluting stent im-

before due to severe aortic regurgitation caused byplantation in the distal LAD (Figures 1I to 1L, Video 3).

a failed bioprosthetic valve (21-mm Carpentier-The patient was discharged 3 days later. Thus, PCI in

Edwards PERIMOUNT [CEP], Edwards Lifesciences,the valve-in-valve setting is feasible with the aid ofIrvine, California). Nuclear myocardial perfusion im-MSCT.

aging with single-photon emission tomography andmultislice computed tomography (MSCT) showed

ADDRESS FOR CORRESPONDENCE: Dr. Shiro Miura,

localized ischemia with heavy calciﬁcation in theDepartment of Cardiology, Hokkaido Ohno Memorial

distalartery

Hospital, 2-1-16-1 Miyanosawa, Nishi-ku, Sapporo,(LAD) (Figures 1A to 1D, Video 1). MSCT depicted063-0052, Japan. E-mail: s.miura@ohno-kinen.or.jp.

leftanterior

descending

coronary

From the aDepartment of Cardiology, Hokkaido Ohno Memorial Hospital, Sapporo, Japan; bDivision of Diagnostic Radiology
Imaging, Hokkaido Ohno Memorial Hospital, Sapporo, Japan; and the cDepartment of Thoracic and Cardiovascular Surgery,
Hokkaido Ohno Memorial Hospital, Sapporo, Japan. The authors have reported that they have no relationships relevant to thecontents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’
institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information,
visit the JACC: Cardiovascular Interventions author instructions page.
Manuscript received May 28, 2020; accepted June 9, 2020.

ISSN 1936-8798/$36.00

https://doi.org/10.1016/j.jcin.2020.06.025

2Miura et al.

JACC: CARDIOVASCULAR INTERVENTIONS VOL.

Multislice CT in Valve-in-Valve TAVR-, NO. -, 2020
- 2020:-–-F I G U R E 1 Pre-Procedural Assessment With Multiple Imaging Modalities and PCI After Valve-in-Valve TAVR

The maximum intensity projection (A) and curved planar reconstruction (B) disclose stenosed lesions with severe calciﬁcation in the distal left anterior descending
coronary artery (LAD). Hybrid images of stress (C) and rest (D) single-photon emission computed tomography (CT) and multislice (MS) CT reveal anteroapicalmyocardial ischemia in the distal LAD (Video 1). Three-dimensional MSCT reconstruction of the valve-in-valve construct and its anatomy in relation to the coronaryartery and aorta (E) (Video 2). En face view from inside the transcatheter heart valve (THV) indicating the closest cell (yellow-dashed square) as a potential accessroute overlapped partially by the THV skirt between 2 commissures (F). Corresponding longitudinal (G) and axial (H) projections through the aortic root (dotted
violet lines in G and H). The target cell is 13.1 mm above the THV inﬂow because the skirt extends 13 mm from the inﬂow bottom. A 7-F Judkins left 3.5 guide catheter
was semiselectively engaged after a 0.014-inch guidewire and a microcatheter advanced into the LAD via the semiopened cell close to the left coronary artery (LCA)
ostium disclosing the occlusive lesion (yellow arrowheads) in the distal LAD (I) (Video 3). After the engagement in support with a 5-F guide extension catheter,rotational atherectomy is performed using a 1.25-mm burr (J) and the lesion is pre-dilated with a 2-mm cutting balloon (K) and deployment of a 2.25-mm stent with aﬁnal angiogram (L). CEP ¼ Carpentier-Edwards PERIMOUNT valve; LCX ¼ left circumﬂex coronary artery; PCI ¼ percutaneous coronary intervention; RCA ¼ rightcoronary artery; TAVR ¼ transcatheter aortic valve replacement.

REFERENCE
1. Yudi MB, Sharma SK, Tang GHL, Kini A. Coronary
angiography and percutaneous coronary intervention after transcatheter aortic valve replacement. J Am Coll Cardiol 2018;71:1360–78.

KEY WORDS multislice computed
tomography, percutaneous coronary
intervention, transcatheter aortic valve
replacement

AP PE NDIX For supplemental videos,please see the online version of this paper.