AbstractGiven that coronary artery disease (CAD) in octogenarians undergoing transcatheter aortic valve implantation (TAVI) often presents with more complex lesions and extensive calcification, rotational atherectomy (RA) may be needed in some cases before stenting. However, data regarding the feasibility and safety of simultaneous RA during TAVI using the Medtronic CoreValve (MCV; Medtronic, Minneapolis, MN, USA) system are lacking. Three out of 107 (2.8%) patients (2 females, average age 85.6 years, mean aortic valve area 0.5 cm2, mean left ventricular ejection fraction 39%, mean Logistic EuroScore 70%), with complex, heavily calcified coronary stenosis, and severe valvular aortic stenosis (AS) were treated with TAVI and RA due to high surgical risk. After balloon valvuloplasty, all coronary lesions were successfully treated with RA and stenting, immediately followed by transfemoral TAVI with a self-expandable MCV. Our data suggested that in the very elderly patients with severe and heavily calcified CAD and AS who were turned down for cardiac surgery, RA and stenting followed by TAVI may be performed successfully in a combined, single-stage procedure

Lee, Yung-Tsai

Wei, Jeng

Yin, Wei-Hsian

Yu, Ho-Ping

Elsevier - Publisher Connector 

Available online at www.sciencedirect.comScienceDirect
Journal of the Chinese Medical Association 79 (2016) 512e516
www.jcma-online.comBrief Communication
Simultaneous rota-stenting and transcatheter aortic valve implantation for
patients with heavily calcified coronary stenosis and aortic stenosis
Yung-Tsai Lee a, Wei-Hsian Yin a,b,*, Ho-Ping Yu a, Jeng Wei a
a Heart Center, Cheng-Hsin General Hospital, Taipei, Taiwan, ROC
b Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
Received January 21, 2016; accepted March 1, 2016AbstractGiven that coronary artery disease (CAD) in octogenarians undergoing transcatheter aortic valve implantation (TAVI) often presents with
more complex lesions and extensive calcification, rotational atherectomy (RA) may be needed in some cases before stenting. However, data
regarding the feasibility and safety of simultaneous RA during TAVI using the Medtronic CoreValve (MCV; Medtronic, Minneapolis, MN, USA)
system are lacking. Three out of 107 (2.8%) patients (2 females, average age 85.6 years, mean aortic valve area 0.5 cm2, mean left ventricular
ejection fraction 39%, mean Logistic EuroScore 70%), with complex, heavily calcified coronary stenosis, and severe valvular aortic stenosis
(AS) were treated with TAVI and RA due to high surgical risk. After balloon valvuloplasty, all coronary lesions were successfully treated with
RA and stenting, immediately followed by transfemoral TAVI with a self-expandable MCV. Our data suggested that in the very elderly patients
with severe and heavily calcified CAD and AS who were turned down for cardiac surgery, RA and stenting followed by TAVI may be performed
successfully in a combined, single-stage procedure.
Copyright © 2016, the Chinese Medical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: coronary artery disease; percutaneous coronary intervention; rotational atherectomy; transcatheter aortic valve implantation; valvular aortic stenosis1. Introduction
Coronary artery diseases (CAD) in octogenarians under-
going transcatheter aortic valve implantation (TAVI) often
present with more complex lesions and extensive calcification,
therefore, rotational atherectomy (RA) may be needed in some
cases prior to stenting.1,2 Until recently, only rare cases of RA
during TAVI have been performed and reported in this very
complex setting.1,2 Although percutaneous coronary inter-
vention (PCI) can be performed successfully after the im-
plantation of a self-expandable Medtronic CoreValve (MCV;Conflicts of interest: The authors declare that they have no conflicts of interest
related to the subject matter or materials discussed in this article.
* Corresponding author. Dr. Wei-Hsian Yin, Division of Cardiology, Heart
Center, Cheng-Hsin General Hospital, 45, Cheng-Hsin Street, Taipei 112,
Taiwan, ROC.
E-mail address: yinwh@pchome.com.tw (W.-H. Yin).
http://dx.doi.org/10.1016/j.jcma.2016.03.007
1726-4901/Copyright © 2016, the Chinese Medical Association. Published by El
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).Medtronic, Minneapolis, MN, USA),2,3 we consider it more
technically challenging than that performed in the presence of
a shorter TAVI prosthesis.
We herein illustrate our thoughts and experiences with the
outcomes from three octogenarians who suffer from severe
and heavily calcified CAD and aortic stenosis (AS). They were
rejected as candidates for cardiac surgery, and Rota-stenting
and TAVI were then performed successfully in a combined,
single-stage procedure. To the best of our knowledge, there
has been no specific prior report addressing this issue.
2. Methods
In all of our cases, RA and stenting were performed after
balloon aortic valvuloplasty (BAV). RA was then performed
through a 12Fr arterial sheath contralateral to the valve
implanting side. The intention was to use only one burr with
the strategy “to be simple and to go fast” in these criticalsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND
Table 2
Angiographic and procedural characteristics of the PCI procedures in the three
patients.
Patient #1 Patient #2 Patient #3
Vascular access Transfemoral Transfemoral Transfemoral
No. of diseased vessels LMþ 3VD LMþ 3VD LMþ 3VD
SYNTAX score 28 35 32
Guiding catheter diameter (Fr) 7 6 6
Target vessel (Rotablation) LM & LAD LM & LAD LM & LAD
Target vessel (PCI only) Nil RCA Nil
Baseline QCA (Rotablation)
Reference vessel diameter (mm) 3.44 2.52 2.72
Lesion length (mm) 28 89 98
Minimal luminal diameter (mm) 0.4 0.3 0.2
Diameter stenosis (%) 88 88 93
Post-procedural QCA
Reference vessel diameter (mm) 3.62 2.80 2.82
Lesion length (mm) 30 92 102
Minimal luminal diameter (mm) 3.24 2.61 2.58
Diameter stenosis (%) 10.4 6.7 8.5
No. of burr used 1 1 1
Largest burr size used (mm) 1.5 1.25 1.25
Type of stent implanted Bare-metal
stent
Drug-eluting
stent
Drug-eluting
stent
No. of stent implanted 2 4 3
Procedural success Yes Yes Yes
Procedural complications None None None
LAD ¼ left anterior descending artery; LM ¼ left main disease;
PCI ¼ percutaneous coronary intervention; QCA ¼ quantitative coronary
analysis; RCA ¼ right coronary artery; 3VD ¼ three-vessel disease.
513Y.-T. Lee et al. / Journal of the Chinese Medical Association 79 (2016) 512e516patients, whose frailty must be taken into account. After
rotablation, the lesions were treated with ballooning and
stenting. Subsequent to PCI, transfemoral TAVI was per-
formed according to the standard procedures previously
described.4
In the present study, all relevant baseline, procedural,
echocardiographic, and follow-up data were retrospectively
collected by a well-trained research assistant, and taken from
our computerized database for analysis. This retrospective
study was approved by the Ethics Committee of Cheng Hsin
General Hospital. All patients were critically reviewed by a
dedicated heart team, and each signed an informed consent for
RA and TAVI before the procedure.
3. Results
Among our consecutive series of 107 transfemoral TAVI
procedures, 68 (63.5%) had significant CAD. Of that number,
31 (29%) were indicated for myocardial revascularization. In
three cases (2.8%) with severe calcified lesions, RA was
needed to improve acute procedural success. The clinical
characteristics of the three patients who underwent concomi-
tant RA and TAVI are detailed in Table 1.
Angiographic and procedural characteristics are detailed in
Table 2. The target vessels for rota-stenting in the three pa-
tients were all long lesions from the left main to the left
anterior descending artery. Among these three cases, RA was
necessary due to a failure to cross a lesion with an intravas-
cular ultrasound catheter, balloons, or a coronary stent (Figs. 1
and 2). Thereafter, angiographic and procedural success
occurred in all three patients.
Additionally, TAVI after PCI resulted in significant he-
modynamic improvement in all three patients. No compli-
cations occurred during or after the procedures, and only
mild or moderate aortic regurgitation was demonstrated
after TAVI. The patients also showed a remarkable recovery
in their clinical status and a much improved quality of life,
their angina disappearing and heart failure symptoms
resolving from New York Heart Association (NYHA) Class
IV to Class II, for up to 1-month following the procedures
(Table 3).Table 1
Clinical characteristics of the three patients who underwent concomitant
rotational atherectomy and transcatheter aortic valve implantation.
Patient #1 Patient #2 Patient #3
Age (y) 83 81 93
Gender Female Female Male
Body mass index (kg/m2) 17.9 16.9 24.6
Smoking No No No
Hypertension No No No
Diabetes Yes No No
Hyperlipidemia Yes Yes No
Previous cerebral vascular accident No No Yes
Chronic kidney disease (Stages 4 & 5) No No No
Previous myocardial infarction No No No
Logistic EuroScore (%) 59 71 80
Left ventricular ejection fraction (%) 40 22 554. Discussion
The optimal timing of PCI for patients undergoing TAVI
remains an issue of ongoing controversy,5e13 which varies
among different institutions. A staged approach, with PCI and
TAVI performed in two separate sessions, has the advantages
of reducing the duration of the TAVI procedure, the volume of
contrast media used, and the risk of hemodynamic instability
due to PCI-related complications during the TAVI.5,6,9,10
Performing PCI and TAVI during a single stage may be a
more practical strategy however, and avoids the risks associ-
ated with an additional invasive procedure.11e13 The onset of
our institution's TAVI program was March 2013. Thereafter,
our heart team adopted the strategy of staged PCI during the
1st year of our TAVI experience, treating concomitant CAD
electively 2e4 weeks before TAVI. However, given the
growing experience of our heart team, and the more mature
skills of the operators, all PCI were performed during the same
TAVI procedure since January, 2014.
From previously reported series, we found three patients
underwent successful RA immediately after TAVI using a
balloon-expandable valve.1 It was assumed that any eventual
ischemic complication related to the PCI procedure (slow flow
or vessel occlusion) would have been better tolerated after the
complete release of the left ventricular (LV) pressure over-
load.1 In another case report, one patient was treated by
complex PCI with RA 15 months after implantation of a MCV
prosthesis.2 However, we consider that some issues need to be
addressed concerning PCI with RA in TAVI with MCV.
Fig. 1. Patient #2. (A) Coronary angiography showing left main disease and LAD artery stenosis before rotablation and stenting (arrows); (B) coronary angiography
showing right coronary artery stenosis before stenting (arrow); (C) BAV before PCI; (D) failure to cross the lesion of the proximal LAD with an intravascular
ultrasound catheter because of marked calcification (arrow); (E) rotablator burr crossing the left main and LAD lesions; (F) coronary angiography showing left
main and LAD after rotablation and stenting; (G) coronary angiography showing RCA after stenting; (H) implantation of a 26 mm MCV prosthesis; (I) final
angiography showing mild aortic regurgitation after MCV implantation (arrow). BAV ¼ balloon aortic valvuloplasty; LAD ¼ left anterior descending;
MCV ¼ Medtronic CoreValve; PCI ¼ percutaneous coronary intervention; RCA ¼ right coronary artery.
514 Y.-T. Lee et al. / Journal of the Chinese Medical Association 79 (2016) 512e516First, although PCI can be done successfully after the im-
plantation of a MCV,2,3 the procedure is more technically
challenging than that performed in conjunction with a shorter
TAVI prosthesis, such as the Edwards Sapien valve or the
Boston Scientific Lotus valve. This is because the MCV is
self-expandable with a longer stent frame. Although at the
sinus of Valsalva level, the prosthesis takes the form of a calix
so as not to compromise the flow of the coronary arteries, it is
necessary to pass the tip of the guiding catheter through the
rhomboid-shaped frames of the prosthesis in order to engage
both coronary ostia. This may be problematic when coaxial
and strong support is required, such as in the case of RA.
Secondly, the advantage of the MCV prosthesis is the
gradual step-by-step deployment process, which permits fine
adjustments to implantation depth and avoidance of interfer-
ence with the surrounding structures. However, it takes longer
to deploy the prosthesis compared to a balloon-expandable
valve. The ischemia related to the rapid ventricular pacing
during valve implantation is very short and unlikely to create
irreversible hemodynamic impairment before PCI when aballoon-expandable valve is used; however, this may be a
serious concern in the scenario of TAVI with MCV. Hence, we
believe it would be safer to perform PCI before, instead of
after, TAVI with MCV.
Thirdly, in order to avoid possible ischemic complication
related to the RA, which is extremely risky and may jeopar-
dize the patient,14 we recommend relieving LV outflow tract
obstruction. This would improve cardiac output and immedi-
ately reduce LV wall stress by balloon aortic valvuloplasty
(BAV) before PCI with RA. Even though permanent elimi-
nation of the transaortic gradient is impossible, BAV may
provide temporary relief of LV outflow tract obstruction or at
least improve the patient's coronary blood flow.15 Of course,
during BAV, the duration of rapid ventricular pacing should be
kept as short as possible to avoid myocardial ischemia and
irreversible hemodynamic impairment before PCI with RA.
Our data did demonstrate that the contrast media volume was
relatively low, even though the fluoroscopy time and total
procedure time was longer. Moreover, using a smaller size of
burr would be more than adequate for partial debulking to
Fig. 2. Patient #3. (A) Coronary angiography showing left main disease and LAD artery stenosis before rotablation and stenting (arrows); (B) failure to cross the
lesion of the proximal LAD with a 2.25 mm  35 mm stent because of marked calcification (arrows); (C) rotablator burr crossing the left main and LAD lesions;
(D) coronary angiography showing left main and LAD after rotablation and stenting; (E) implantation of a 29 mm MCV prosthesis; (F) final angiography showing
mild aortic regurgitation after MCV implantation. LAD ¼ left anterior descending; MCV ¼ Medtronic CoreValve.
515Y.-T. Lee et al. / Journal of the Chinese Medical Association 79 (2016) 512e516allow the alteration of plaque compliance and facilitate
appropriate stent expansion.
In conclusion, RA and TAVI can be performed successfully
in a combined, single-stage procedure without increasing the
risks of renal failure in very high-risk octogenarians presenting
with more complex coronary lesions and extensive calcifica-
tion, who are primarily denied surgical revascularization.
Prospective comparisons with a larger number of patients andTable 3
Procedural characteristics and outcomes of the transcatheter aortic valve im-
plantation procedures in the three patients.
Patient #1 Patient #2 Patient #3
Vascular access TF TF TF
Pre-procedural parameters
NYHA functional class IV IV IV
Aortic valve area (cm2) 0.3 0.6 0.6
Mean pressure gradient (mmHg) 41 48 24
Aortic annulus diameter (mm) 22.3 23.6 25.2
Aortic regurgitation (grade) Moderate Mild Mild
Medtronic CoreValve size (mm) 26 26 29
Post-procedural parameters
NYHA functional class II II II
Aortic valve area (cm2) 1.4 1.7 1.8
Mean pressure gradient (mmHg) 8 7 6
Aortic regurgitation (grade) Mild Mild Mild
Procedural success Yes Yes Yes
Post-operative complication by VARC None None None
Mortality at 1-month follow-up No No No
NYHA functional class at 1-mo II II II
Aortic regurgitation at 1-mo Mild Mild Mild
NYHA¼New York Heart Association; TF ¼ transfemoral; VARC¼Valve
Academic Research Consortium.long-term follow-up are required to confirm these potential
advantages.
Acknowledgments
We thank Ms. Clair Tang and Ms. Chin-Feng Chen for their
assistance in preparing this manuscript.
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Simultaneous rota-stenting and transcatheter aortic valve implantation for patients with heavily calcified coronary stenosis and aortic stenosis 

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Simultaneous rota-stenting and transcatheter aortic valve implantation for patients with heavily calcified coronary stenosis and aortic stenosis

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