Abstract
We present a case of an 83-year-old female who suffered from annular rupture with contained hematoma immediately after trans-apical implantation of balloon-expandable Sapien valve. The patient developed acute cardiogenic shock which resulted from an extrinsic compression of the left main coronary artery. We report the successful management of this complication.
Highlights
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A unique case report of contained annular rupture after trans-apical TAVR using a balloon-expanding valve.
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Rupture caused extrinsic compression of LMCA with hemodynamic collapse.
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This was identified immediately and treated by stenting.
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Patient’ outcome was uneventful, and she is in good functional class at 6 months.
1
Introduction
Trans-catheter aortic valve implantation (TAVI) is widely recognized as an alternate therapy for patients with severe aortic stenosis and high surgical risk for conventional surgical valve replacement. However, this procedure has inherent risks that physicians must recognize and understand. Rupture of the device landing zone, albeit rare, is one of the most lethal complications. We describe the case of an acute hemodynamic collapse after a contained rupture and a successful percutaneous treatment of this complication.
2
Case presentation
An 82-year-old woman with symptomatic severe aortic stenosis, logistic EuroSCORE I (European System for Cardiac Operative Risk Evaluation) of 19.6%, EuroSCORE II of 2.27%, and Society of Thoracic Surgeons’ (STS) estimated surgical mortality of 3.12%, underwent TAVI. Trans-thoracic echocardiogram (TTE) showed a heavily calcified aortic valve with peak aortic gradient of 60 mmHg, ean gradient of 40 mmHg, Vmax of 388 cm/sec, calculated aortic valve area of 0.5 cm 2 , and good left ventricular systolic function. Computed tomographic angiography (CTA) demonstrated heavily calcified aortic root, leaflets, and annulus ( Fig. 1 ). Annulus’ diameters were 18 mm by 26.6 mm, perimeter was 63 mm, and average diameter was 22.1 mm. CTA also showed small (< 5 mm) ileo-femoral arteries not suitable for trans-femoral access. Therefore, the decision of “heart team” was to refer her to trans-apical implantation of a 23 mm Edwards-Sapien XT (Edwards Lifesciences, Irvine, CA, USA) valve.
Pre-dilation was performed using a 20 mm balloon, and the valve was implanted successfully in a 50–50 position. However, the immediate post-deployment aortogram showed leakage of die outside the left sinus ( Fig. 2 ). There was no evidence of cardiac tamponade, hence the hematoma was contained around the aortic root. Despite that fact, the patient developed immediate hemodynamic collapse. QRS widening and ST-elevation on monitor leads were noticed. Angiographic images showed that the left main coronary artery (LMCA) is narrowed and collapsed with reduced TIMI flow ( Fig. 2 ). Trans-esophageal echocardiogram that was used throughout the procedure confirmed the presence of a contained hematoma compressing the left main coronary artery ( Fig. 3 ). An emergent percutaneous intervention was performed within minutes from collapse a deployment of two drug-eluting stents from LMCA into LAD and from LMCA into left circumflex artery using the cullotte technique with final kissing-balloon dilatation ( Fig. 4 ). After the restoration of coronary flow, the patient had been stabilized, chest was closed, and she was admitted to the cardio-thoracic intensive care unit.
