Abstract
The left atrial dissection is a very infrequently encountered complication after valve replacement and never seen after Transcatheter aortic valve replacement (TAVR). We present an 84-year-old female, who underwent successful transapical TAVR and consequently developed contained left atrial dissection seen on transesophageal echocardiogram. The patient remained stable throughout the procedure and was monitored in critical care unit with conservative management. Although there is low associated intraop mortality, prompt recognition is paramount with follow-up serial imaging.
The left atrial dissection (latD) is a very rare complication, encountered typically after mitral valve surgery . There are only three reported cases of latD after surgical aortic valve replacement, with the first case described by Osawa H et al. in 2003 . We are reporting the first case of latD after trans-apical transcatheter aortic valve replacement (TA-TAVR).
An 84 year old female with significant history of coronary artery bypass grafting, severe peripheral arterial disease and aortic stenosis (AS) was sent for TAVR. Pre-surgical workup revealed severe AS, mild mitral regurgitation and LVEF of 40%, annulus diameter by computerized tomography angiography (CTA) of 26 × 21 mm, and annulus area of 410 mm 2 , and a TA-TAVR using 26 mm Edward SAPIEN XT valve (Edwards Lifesciences, Irvine, California) was planned. The pre-operative 12-lead electrocardiogram (ECG) revealed sinus rhythm without significant interventricular conduction delay (IVCD).
Access was obtained from left 5th intercostal space using standard surgical technique and with standard precaution technique for TA TAVR. After exposing the apex of the heart, two pledgeted 2-0 Prolene mattress sutures into the apex were deployed, keeping ACT greater than 300 s. A 6 F JR 4 catheter is advanced over the 0.035 J tip soft wire and later exchanged out for a stiff Amplatzer wire, which was positioned in the descending aorta. Edwards TA (Ascendra) delivery system was advanced up to 4 cm through the apex of the left ventricle and positioned into the left ventricle outflow tract (LVOT). A 26 mm Edward SAPIEN XT valve, prepped, and crimped in correct orientation was advanced under fluoroscopy into the native aortic annulus; however resistance was noticed while advancing the system across the LVOT, which required repositioning of the stiff Amplatzer wire and the delivery system. At this point, a flap was noticed in the left atrium (LA) by trans-esophageal echocardiography [TEE] ( Fig. 1 A and B, Movie 1 ). After rapid pacing, the valve was slowly deployed with an excellent final result and no evidence of aortic insufficiency.
Subsequent TEE images suggested a disruption of the AV groove at the base of the posterior mitral leaflet with LA posterior wall dissection. There was a significant retrograde mitral regurgitation jet into the pseudo-chamber ( Fig. 1 C); however there was only mild mitral regurgitation into the true LA. Throughout the procedure, the patient remained hemodynamically stable and conservative treatment decision was carried out. Post valve deployment ascending aorta angiogram confirmed no aortic dissection and significant aortic insufficiency, with similar findings confirmed on TEE. On postoperative day 1, CTA confirmed the LA posterior wall dissection and all four pulmonary veins drained into the true LA chamber ( Fig. 2 A and B). The patient was discharged post op day 5 to rehabilitation center. She was stable at her 30-day visit; however six months later she suffered Clostridium difficile infection and died due to septic shock.
