Aortic annular rupture during TAVR: Mini review




1. Background


Aortic annular rupture is a catastrophic TAVR complication often requiring immediate bail-out surgery and it is associated with increased mortality. Larger registries report periprocedural aortic annular rupture in < 1% of the total procedures, although “silent” concealed ruptures are believed to be more frequent . They are more common with balloon-expandable valves and in elderly women with fragile tissue where bulky calcifications may perforate the aortic root . Although a systematic analysis of aortic annular ruptures is currently unavailable, they are thought to occur due to poor patient selection, lack of experience, suboptimal measurement of the root diameters, aggressive post-dilatation, valve oversizing > 20%, and excessive annular calcification . Unexplained hypotension with development of pericardial effusion should prompt urgent echocardiographic and angiographic evaluation to identify potential rupture . Emergent intervention can be life saving.




2. Case presentation


A 99 year-old Caucasian female was referred to our center after a recent successful balloon aortic valvuloplasty for critical aortic stenosis which had provided remarkable symptomatic relief. She had a history of hypertension, TIA, chronic kidney disease stage 3 with GFR 35 ml/min and valvular cardiomyopathy with EF 35–40%.


A transthoracic echocardiogram revealed a heavily calcified aortic valve with restricted leaflet excursion and mild aortic insufficiency. Her CT scan showed severe amount of calcium that appeared mostly around the annulus down into the LVOT bridging into MAC ( Fig. 1 ). There was little calcium on the leaflets. Her annulus area was measured as 407.4mm 2 . These measurements suggested that a 23 mm Sapien XT would be appropriate with a 2% oversizing.




Fig. 1


Preprocedural Computed Tomography.

Severe calcification of the aortic annulus (arrow) extending into the left ventricular outflow tract.


We planned a minimalistic TAVR approach with local and conscious sedation via transfemoral approach using the SAPIEN XT valve. Verbal and written informed consent was obtained after evaluation by our hospital multi-disciplinary heart team.


After obtaining bilateral transfemoral access without complications, a balloon valvuloplasty was performed using a 20 mm balloon. Under fluoroscopic and echocardiographic guidance a 23 mm SAPIEN XT valve was deployed under rapid ventricular pacing at 180 bpm. The patient tolerated the procedure well without residual transaortic gradient. However, transthoracic echocardiography revealed a small pericardial effusion and a communication between the aortic root and the right ventricle, suggestive of aortic root rupture ( Fig. 2 ).




Fig. 2


Intraprocedural Transthoracic Echocardiographic Images.

Parasternal long axis view showing a high velocity jet (white arrow) entering the right ventricle (A); five chamber apical view showing a communication between the left ventricular outflow tract and the right ventricle (white arrow) (B); subcostal view showing a large pericardial effusion(white arrow) (C).


The patient was immediately transferred to the operating room for a planned aortic root repair. The exact location of the rupture could not be identified. After the excision of the SAPIEN XT valve, an emergent aortic valve and aortic root replacement with a 21 mm and 22 mm Hancock II bioprosthetic valve and Gelweave valve conduit (Bentall procedure) and a right ventricular repair was performed. The patient failed bypass weaning due to profound hypotension, bradycardia and ventricular fibrillation. A large area of bruising was found in the area of the LAD distribution which was suspected to be secondary to intramyocardial hematoma. After unsuccessful attempts to wean from cardiopulmonary bypass the patient expired.




2. Case presentation


A 99 year-old Caucasian female was referred to our center after a recent successful balloon aortic valvuloplasty for critical aortic stenosis which had provided remarkable symptomatic relief. She had a history of hypertension, TIA, chronic kidney disease stage 3 with GFR 35 ml/min and valvular cardiomyopathy with EF 35–40%.


A transthoracic echocardiogram revealed a heavily calcified aortic valve with restricted leaflet excursion and mild aortic insufficiency. Her CT scan showed severe amount of calcium that appeared mostly around the annulus down into the LVOT bridging into MAC ( Fig. 1 ). There was little calcium on the leaflets. Her annulus area was measured as 407.4mm 2 . These measurements suggested that a 23 mm Sapien XT would be appropriate with a 2% oversizing.




Fig. 1


Preprocedural Computed Tomography.

Severe calcification of the aortic annulus (arrow) extending into the left ventricular outflow tract.


We planned a minimalistic TAVR approach with local and conscious sedation via transfemoral approach using the SAPIEN XT valve. Verbal and written informed consent was obtained after evaluation by our hospital multi-disciplinary heart team.


After obtaining bilateral transfemoral access without complications, a balloon valvuloplasty was performed using a 20 mm balloon. Under fluoroscopic and echocardiographic guidance a 23 mm SAPIEN XT valve was deployed under rapid ventricular pacing at 180 bpm. The patient tolerated the procedure well without residual transaortic gradient. However, transthoracic echocardiography revealed a small pericardial effusion and a communication between the aortic root and the right ventricle, suggestive of aortic root rupture ( Fig. 2 ).


Nov 13, 2017 | Posted by in CARDIOLOGY | Comments Off on Aortic annular rupture during TAVR: Mini review

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