Abstract
We describe a challenging case of successful use of emergent veno-arterial extracorporeal membrane oxygenation and valve-in-valve transcatheter aortic valve implantation with a Sapien S3 valve.
Highlights
- •
Valve-in-valve TAVR is effective for patients with degenerated bioprosthetic valve.
- •
The role of TAVR in acute bioprosthetic valve failure and acute regurgitation is not clear.
- •
VA-ECMO in cardiogenic shock and bioprosthetic valve disease is an option for patients undergoing emergent TAVR.
1
Introduction
Elective transcatheter aortic valve replacement (TAVR) is a well-established procedure with expanding indication for intermediate-, high-, or extreme-surgical-risk patients with severe aortic stenosis (AS). Valve-in-valve TAVR is also an effective treatment for patients with degenerated bioprosthetic valve [ ]. The role of TAVR as an emergent therapy in acute bioprosthetic valve failure and in particular acute regurgitation is less clear. We report the case of a patient presenting with cardiogenic shock caused by acute rupture of a prosthetic aortic valve leaflet successfully treated with emergent veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and then valve-in-valve TAVR.
2
Clinical summary
A 70-year-old man was taken to a local hospital after acute collapse and cardiogenic shock while at work. His prior history included repair of coarctation of the aorta at the age of 13 and surgical aortic valve replacement (Abbott Trifecta #25 pericardial bioprosthesis, Minneapolis, MN) and left internal mammary artery (LIMA) to left anterior descending (LAD) artery at the age of 65 for AS and coronary artery disease. He had been doing well for the past 5 years, with his last transthoracic echocardiogram (TTE) 1 month prior to presentation showing a normal-functioning bioprosthetic valve and normal left ventricular (LV) function.
On arrival to our hospital, the patient was hypotensive (80/50 mm Hg), tachycardic (104 beats per minute), hypoxemic (SaO 2 87%), and tachypneic (30 breaths per minute). He was initially placed on non-invasive ventilation but then required intubation with consequent refractory hypoxia despite FiO 2 of 100% and PEEP of 12 mm Hg. He also required initiation of inotropes for blood pressure support. He had cool extremities and rales on examination with an elevated lactate (2.5 mmol/L), transaminitis (290/52 AST/ALT U/L), elevated troponin I (peak 80 ng/mL) and acute kidney injury (2.5 mg/dL and oliguric; previously normal renal function) with chest X-ray showing diffuse pulmonary edema. Electrocardiogram showed sinus rhythm with non-specific ST-T wave abnormalities. A transesophageal echocardiogram (TEE) demonstrated acute worsening of LV function with ejection fraction (EF) of 20–25% with new severe aortic regurgitation and mobile echoes within the prosthesis suggesting a flail leaflet. One leaflet appeared to have ruptured and prolapsed to and fro across the annulus. No dissection of the ascending aorta or aortic root abscess was noted ( Movies 1, 2, 3 ; Fig. 1 ). In the setting of cardiogenic shock with severe aortic regurgitation and refractory hypoxemia, the patient was not considered a candidate for intra-aortic balloon pump (IABP) or Impella, and therefore we elected to perform emergency percutaneous cannulation for peripheral VA-ECMO. This was initiated within 12 h of arrival. Surgical re-operative AVR was deemed prohibitively high risk and, therefore, an emergent TAVR was performed 18 h into his admission.
Arterial access was obtained under angiographic and sonographic guidance. A 26 mm Sapien S3 valve (Edwards Lifesciences, Irvine, CA) was selected and inserted via left femoral artery access using a 14F expandable sheath. After valve deployment, no residual aortic regurgitation or paravalvular leak was noted by angiogram and TEE ( Movies 4, 5, 6 ; Fig. 2 ). Selective coronary angiography revealed a patent LIMA graft to LAD and no other significant coronary artery disease. Of note, the patient’s LV end diastolic pressure reduced from 70 mm Hg to 20 mm Hg after TAVR. The patient returned to the ICU and quickly weaned off vasopressors. His end-organ function completely normalized within 48 h. ECMO decannulation was possible after 18 h post-TAVR procedure and the patient was discharged home on hospital day 10.
With the initial possibility of infective endocarditis (Duke Criteria met with one major criterion considering new valvular regurgitation and one minor criterion given predisposing factor of bioprosthetic valve) [ ], the patient had been started on empiric antibiotics that were continued for 4 weeks until follow-up, when all blood cultures returned negative for infection. At 1-month follow-up, the patient demonstrated remarkable recovery with New York Heart Association (NYHA) Class I symptoms. He continued with outpatient rehabilitation and was able to return to work. At that time, TTE demonstrated normalization of cardiac function with LVEF of 50–55% with borderline global hypokinesis and mild reduction of right ventricular function. The TAVR valve appeared well-seated with a mean aortic gradient of 9 mm Hg and no regurgitation ( Movies 7, 8, 9 ; Fig. 3 ).
2
Clinical summary
A 70-year-old man was taken to a local hospital after acute collapse and cardiogenic shock while at work. His prior history included repair of coarctation of the aorta at the age of 13 and surgical aortic valve replacement (Abbott Trifecta #25 pericardial bioprosthesis, Minneapolis, MN) and left internal mammary artery (LIMA) to left anterior descending (LAD) artery at the age of 65 for AS and coronary artery disease. He had been doing well for the past 5 years, with his last transthoracic echocardiogram (TTE) 1 month prior to presentation showing a normal-functioning bioprosthetic valve and normal left ventricular (LV) function.
