Preoperative Coronary Angiogram in Patients with Aortic Valve Endocarditis Technical Considerations.

Infective endocarditis is associated with increased embolic events risk, different clinical and echocardiographic features have been described as predictors of increased septic emboli risk such as the length (>10 mm), vegetations with mobility, or infective endocarditis with certain pathogens.[1] Many patients with embolic events require urgent valve surgery.[2] A preoperative coronary angiogram is indicated in patients with atherosclerotic risk factors, and in patients who present with myocardial infarction presumably secondary to septic emboli;[3] however, there is a concern about increased embolic risk in patients with aortic valve endocarditis.[4]

It is important in cases of aortic valve endocarditis to minimize catheter manipulation close to the valve, particularly in the presence of mobile vegetation or a history of septic emboli. In this article, we propose a few technical tips for a safe coronary angiogram in patients with aortic valve endocarditis.

REVIEW PRIOR ANGIOGRAM WHEN AVAILABLE

Reviewing prior angiogram even if it is old is helpful in many aspects:

An old angiogram will give an idea about the size and dominance of coronary arteries. If the right coronary artery is known to be nondominant, very small, or not suitable for revascularization you may not need to cannulate it

Coronary anomalies are rare but – when present – they pose technical challenges and increase the procedure duration.[5] An old angiogram shows the origin of the coronary arteries and what were the catheters used to engage the coronary ostium and this helps to minimize catheter manipulation in the ascending aorta.

REVIEW ECHOCARDIOGRAPHIC FINDINGS

Patients with dilated ascending roots may need a different catheter to engage the coronary ostium. For example, Judkins left with a longer secondary curve (JL5 or JL6) may be needed to engage the left coronary system in patients with dilated aortic root [Figure 1].

Figure 1

In the case of the dilated aortic root, the use of Judkins left with a longer secondary curve may be needed

ARTERIAL ACCESS SELECTION

Radial access is not associated with an increased risk of stroke as compared with femoral access among patients with the acute coronary syndrome.[6] There is no data to support the superiority of either access in patients with aortic valve endocarditis. In a large analysis of 1345 patients with infective endocarditis, anticoagulation was found to be an independent predictor of neurological complications (hemorrhagic stroke, HR: 2.7).[7] Hence, it may reasonable to use femoral access to avoid the use of anticoagulation with radial access.

CATHETER SELECTION

we recommend using the “workhorse catheter “which is typically used by the operator in daily practice; however, it may be reasonable to avoid catheters that require excessive manipulation at the level of the aortic valve (Amplatz left or multipurpose catheter) [Figure 2]. Judkins left and right require minimal manipulation and may be ideal to engage the left and right coronary systems without the need to go the valve cusps [Figure 3].

Figure 2

Amplatz type catheters. (a) AL, (b) AR, require to use aortic valve cusps support for engagement which may increase the risk of embolization in aortic valve endocarditis

Figure 3

Judkins-type catheter enables engagement without getting in very close proximity to the aortic valve vegetation

IN SUMMARY

In this brief report, we described the standard technique we use in preoperative angiograms in patients with aortic valve endocarditis, we believe these steps help to minimize the embolization risk in this devastating disease.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.