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Year : 2022  |  Volume : 23  |  Issue : 2  |  Page : 100-102  

Preoperative coronary angiogram in patients with aortic valve endocarditis technical considerations

Department of Cardiovascular Medicine, Heart Hospital, Hamad Medical Corporation, Doha, Qatar

Date of Submission27-May-2021
Date of Acceptance07-Jun-2022
Date of Web Publication23-Jul-2022

Correspondence Address:
Dr. Abdulrahman Arabi
Senior Consultant, Adult Cardiology Department, Heart Hospital, Hamad Medical Corporation, P. O. Box 3050, Doha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/heartviews.heartviews_60_21

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How to cite this article:
Arabi A, Arafa S, Al-Qahtani A, Osman OT, Alsuwaidi J. Preoperative coronary angiogram in patients with aortic valve endocarditis technical considerations. Heart Views 2022;23:100-2

How to cite this URL:
Arabi A, Arafa S, Al-Qahtani A, Osman OT, Alsuwaidi J. Preoperative coronary angiogram in patients with aortic valve endocarditis technical considerations. Heart Views [serial online] 2022 [cited 2023 Oct 3];23:100-2. Available from: https://www.heartviews.org/text.asp?2022/23/2/100/351871

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 Top

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

  1. 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
  2. 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 Top

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

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   Arterial Access Selection Top

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 Top

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

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Figure 3: Judkins-type catheter enables engagement without getting in very close proximity to the aortic valve vegetation

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   In Summary Top

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.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Di Salvo G, Habib G, Pergola V, Avierinos JF, Philip E, Casalta JP, et al. Echocardiography predicts embolic events in infective endocarditis. J Am Coll Cardiol 2001;37:1069-76.  Back to cited text no. 1
Habib G, Lancelloti P, Antunes MJ, Bongiorni MG, Casalta JP, Zotti FD, et al. The 2015 ESC Guidelines for the management of infective endocarditis. Eur. Heart J 2015;36:3075-128.  Back to cited text no. 2
Roxas CJ, Weekes AJ. Acute myocardial infarction caused by coronary embolism from infective endocarditis. J Emerg Med 2011;40:509-14.  Back to cited text no. 3
Hekimian G, Kim M, Passefort S, Duval X, Wolff M, Leport C, et al. Preoperative use and safety of coronary angiography for acute aortic valve infective endocarditis. Heart 2010;96:696-700.  Back to cited text no. 4
Angelini P. Normal and anomalous coronary arteries: Definitions and classification. Am Heart J 1989;117:418-34.  Back to cited text no. 5
Patel VG, Brayton KM, Kumbhani DJ, Banerjee S, Brilakis ES. Meta-analysis of stroke after transradial versus transfemoral artery catheterization. Int J Cardiol 2013;168:5234-8.  Back to cited text no. 6
García-Cabrera E, Fernández-Hidalgo N, Almirante B, Ivanova-Georgieva R, Noureddine M, Plata A, et al. Neurological complications of infective endocarditis: Risk factors, outcome, and impact of cardiac surgery: A multicenter observational study. Circulation 2013;127:2272-84.  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3]


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