We appreciate the comments of Ozturk et al on our publication entitled, “Coronary Thromboembolism During Transcatheter Aortic Valve Replacement”.1
The case in question concerned a patient with high thromboembolic risk who received 2 drug-eluting stents in the anterior descending artery during coronary angiography 1 month before the valve replacement procedure. The patient received dual antiplatelet therapy after the angioplasty and, later, unfractionated heparin during the transcatheter aortic valve implantation to maintain an activated clotting time between 200 and 250 s. Thus, the patient received complete antithrombotic therapy despite a high risk of bleeding (hypertension, diabetic nephropathy, and chronic alcoholic liver disease). We do not know if there were fluctuations in the anticoagulation level during the procedure. After the implant, the patient continued to receive dual antiplatelet therapy. Although coronary thromboembolic complications during aortic valve implantation are infrequent (around 1%2), they can be catastrophic3 and thus require urgent treatment.
Calcifications in the left ventricular outflow tract, the native aortic valve itself, and the ascending aorta can lead to certain complications.4–6 Another possible complication to bear in mind is coronary embolism of calcified material. In our patient, the presence of an intracoronary thrombus was revealed using a thromboaspiration device. Because this device is designed to remove intravascular thrombi, it helped to achieve optimal myocardial perfusion.
Cases such as this one reinforce the need for adequate procedure-related antithrombotic therapy, in addition to transesophageal echocardiography monitoring to permit early detection of complications requiring urgent management, as well as for other uses.