title: When we should say no to TAVR-Defining the line between utility and futility.
abstract: History of prior coronary artery bypass surgery (CABG) is a frequent scenario encountered in patients with severe symptomatic aortic stenosis deemed inoperable and referred for transcatheter aortic valve replacement (TAVR). Aside from indices of frailty and other comorbidities, these patients remain at higher risk for peri-operative mortality and morbidity compared to their counterparts without prior CABG. Presence of concomitant peripheral arterial disease and patent left internal mammary artery (LIMA) graft pose further access related challenges. We present a case of an 84-year-old female with prior CABG and severe PAD who underwent transapical TAVR for severe symptomatic AS sustaining an acute myocardial injury from damage to her apical epicardial collateral circulation. The case entails the importance of recognition of epicardial coronary collateralization where a transapical approach is best avoided or further aided by utilization of peri-procedural angiographic/fluoroscopy guidance to avoid epicardial vascular injury.
authors.affiliation: Cooper University Hospital, Camden, NJ 08109, USA.
authors.forename: Zubair A
authors.initials: ZA
authors.lastname: Khan
authors.affiliation: Cooper University Hospital, Camden, NJ 08109, USA.
authors.forename: Janah
authors.initials: J
authors.lastname: Aji
authors.affiliation: Staten Island University Hospital, Staten Island, NY 10314, USA; Brown University, Warren Alpert Medical School, RI 02903, USA.
authors.forename: Armaghan
authors.initials: A
authors.lastname: Soomro
authors.affiliation: Brown University, Warren Alpert Medical School, RI 02903, USA.
authors.forename: Sara
authors.initials: S
authors.lastname: Malik
authors.affiliation: Brown University, Warren Alpert Medical School, RI 02903, USA.
authors.forename: Wajeeha
authors.initials: W
authors.lastname: Saeed
authors.affiliation: Cooper University Hospital, Camden, NJ 08109, USA; Brown University, Warren Alpert Medical School, RI 02903, USA. Electronic address: rizwansardar@hotmail.com.
authors.forename: M Rizwan
authors.initials: MR
authors.lastname: Sardar
mesh_terms: D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*; D006328:Cardiac Catheterization / Q000009:adverse effects* / Q000295:instrumentation; D003097:Collateral Circulation; D017023:Coronary Angiography; D001026:Coronary Artery Bypass / Q000009:adverse effects; D003326:Coronary Circulation; D004562:Electrocardiography; D017809:Fatal Outcome; D005260:Female; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects* / Q000295:instrumentation; D006801:Humans; D018447:Medical Futility; D009203:Myocardial Infarction / Q000209:etiology; D018579:Patient Selection; D058729:Peripheral Arterial Disease / Q000150:complications / Q000503:physiopathology; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome
keywords: Complications; Coronary collaterals; Myocardial infarction; Transcatheter aortic valve replacement