Structural heart disease: Complications and techniques

Acute Artery Occlusion During Transcatheter Aortic Valve Replacement in a Patient With an Anomalous Origin of the Left Circumflex Coronary Artery

Juan Gabriel Acosta-Vélez, MD
Bruno García del Blanco, MD
Josep Guindo, MD
Jose Montiel Serrano, MD
Hug Cuellar Calabria, MD
Gerard Martí Aguasca, MD
Teresa Gonzalez-Alujas, MD
Ignasi Durán, MD
Pilar Tornos, MD, PhD

The images presented are of an 86-year-old woman with severe aortic stenosis in whom a transcatheter aortic valve replacement (TAVR) was performed ( Fig. 4.1 , Online ). Preprocedural angiography revealed an anomalous origin of the left circumflex coronary artery (LCx) from the right coronary sinus below the ostium of the right coronary artery with a retroannular trajectory, as shown by a computed tomography scan. As a preventive measure, an intracoronary catheter and a 0.014-inch guidewire were positioned in the LCx at the beginning of the TAVR procedure. After balloon inflation and liberation of the 26-mm SAPIEN XT valve (Edwards Lifesciences, Irvine, California), severe narrowing of the LCx was documented with no immediate evidence of hemodynamic or electrocardiographic repercussions. Administration of intracoronary nitroglycerin showed no luminal improvement, which supports the hypothesis of extrinsic compression. It was, therefore, treated with an uneventful implantation of a bare-metal stent in the LCx. Computed tomography-adapted cover index was 17%, and relative oversizing was 20%. We can speculate that the use of a smaller prosthesis size may have resulted in a lesser degree or absence of coronary compression. The left coronary artery (LCA) is the most commonly involved artery in reported cases of acute arterial occlusion during TAVR. Most of these cases are due to ostial compression. Nevertheless, when the LCx originates from the right coronary sinus, compression at the posterior aortic annulus should also be considered to undertake preventive measures, as highlighted by our case.

FIG. 4.1

Acute Occlusion of Anomalous Left Circumflex Coronary Artery (LCx) During Transcatheter Aortic Valve Replacement (TAVR).

(A) Preprocedural angiography showing an anomalous origin of the LCx from the right coronary sinus (Online ). (B) Coronary computed tomography scan shows the relationship between the anomalous LCx and the aortic annulus. (C) LCx compression after balloon inflation during the TAVR procedure (Online ). (D) Final result after stent implantation in the LCx (Online ).


  • 1. Ribeiro HB, Nombela-Franco L, Urena M, et. al.: Coronary obstruction following transcatheter aortic valve implantation: a systematic review.JACC Cardiovasc Interv 2013; 6: pp. 452-461.

  • 2. Ribeiro HB, Webb JG, Makkar RR, et. al.: Predictive factors, management and clinical outcomes of coronary obstruction following transcatheter aortic valve implantation: insights from a large multicenter registry.J Am Coll Cardiol 2013; 62: pp. 1552-1562.

  • 3. Gogas BD, Zacharoulis AA, Antoniadis AG: Acute coronary occlusion following TAVI.Catheter Cardiovasc Interv 2011; 77: pp. 435-438.

  • 4. Binder RK, Webb JG, Willson AB, et. al.: The impact of integration of a multidetector computed tomography annulus area sizing algorithm on outcomes of transcatheter aortic valve replacement: a prospective, multicenter, controlled trial.J Am Coll Cardiol 2013; 62: pp. 431-438.

Anterior Mitral Leaflet Perforation During Transcatheter Aortic Valve Replacement in a Patient With Mitral Annular Calcification

Mike Saji, MD
Gorav Ailawadi, MD
Michael Ragosta, MD
Dale E. Fowler, MD, RDCS
John M. Dent, MD
D. Scott Lim, MD

A 71-year-old man with symptomatic severe aortic stenosis was referred for transcatheter aortic valve replacement (TAVR). His medical history included paroxysmal atrial fibrillation, mild mitral regurgitation, and moderate mitral stenosis with a 10 mm Hg mean transmitral gradient determined using transthoracic echocardiography. Computed tomography (CT) showed mitral annular calcification (MAC) mainly distributed on the anteromedial side of the mitral valve ( Fig. 4.2 A–B). The aortic annulus area, as evaluated using CT, was 600 cm 2 , and a 29-mm Edwards SAPIEN XT valve (Edwards Lifesciences, Irvine, California) was implanted in the optimal position without difficulty ( Fig. 4.2 C). However, intraoperative transesophageal echocardiography showed a perforation on the medial side of the anterior mitral leaflet (AML) ( Fig. 4.2 D–G, Online and ). On fluoroscopy, the edge of the SAPIEN XT valve reached the MAC ( Fig. 4.2 H). The postprocedural course was uneventful except for transitional atrial fibrillation, and the patient was discharged on the third postoperative day. Transthoracic echocardiography at the 1-month follow-up did not show evidence of heart failure, infective endocarditis, or deterioration of the transmitral gradient.

FIG. 4.2

Images of Anterior Mitral Leaflet Perforation.

(A and B) Three-dimensional (3D) computed tomography showing significant mitral annular calcification (MAC) ( arrow ). (C) Transesophageal echocardiography (TEE) showing the SAPIEN XT (Edwards Lifesciences, Irvine, California) in the optimal position. (D) Anterior mitral leaflet perforation ( arrow ) (Online ). (E–G) Mitral leaflet perforation on 3D TEE ( arrows ) (Online ). (H) SAPIEN XT reaching the MAC on fluoroscopy ( arrow ). AML , anterior mitral leaflet; AO , aorta; AV , aortic valve; LA , left atrium; Lat , lateral; LV , left ventricle; Med , medial; MR , mitral regurgitation; PML , posterior mitral leaflet; RV , right ventricle.

Acute AML perforation is a rare complication of TAVR. Mitral valve involvement is more likely with the CoreValve prosthesis (Medtronic, Minneapolis, Minnesota) than with the SAPIEN XT valve because it has a larger component extending into the left ventricular outflow tract. However, in this case, the edge of the expanded SAPIEN XT valve impinged the calcification around the mitral valve, resulting in AML perforation. MAC is considered a risk factor for mitral leaflet perforation, which can lead to heart failure and infective endocarditis. Further follow-up is required in this case, and precise CT assessment for MAC is warranted before TAVR.


  • 1. Raschpichler M, Seeburger J, Strasser RH, Misfeld M: Corevalve prosthesis causes anterior mitral leaflet perforation resulting in severe mitral regurgitation and subsequent endocarditis.Eur Heart J 2014; 35: pp. 1587.

  • 2. Franco E, de Agustín JA, Hernandez-Antolin R, et. al.: Acute mitral stenosis after transcatheter aortic valve implantation.J Am Coll Cardiol 2012; 60: pp. e35.

Aortic Root Intussusception During Transcatheter Aortic Valve Replacement

Ayman Jubran, MD
Moshe Y. Flugelman, MD
Nader Khader, MD
Ronen Jaffe, MD

Accurate valve positioning during transcatheter aortic valve replacement (TAVR) is crucial. Valve migration into the left ventricle during deployment can be treated by pulling the valve toward the aortic root or by implanting a second valve.

An 83-year-old woman with severe symptomatic aortic stenosis (valve area 0.80 cm 2 ) was referred for TAVR. Computed tomographic angiography revealed a mildly calcified tricuspid aortic valve (960 Agatston units), minimal calcification within the ascending aorta, and aortic annular dimensions of 21 × 25 mm. A 29-mm CoreValve (Medtronic, Minneapolis, Minnesota) was implanted without predilation.

Implantation was initiated after optimal valve position had been achieved ( Fig. 4.3 , Online ), but the valve descended significantly into the ventricle during deployment, resulting in severe aortic regurgitation ( Fig. 4.4 , Online ). Attempts to pull the valve proximally resulted in intussusception of the aortic annulus into the aorta, with deformation of the aortic root ( Fig. 4.5 , Online ). The deformity resolved after tension on the delivery system was released. Despite the deep final position of the valve (12 mm below the aortic annulus), contact between the distal sealing skirt and the annulus prevented paravalvular leak ( Fig. 4.6 , Online ). The temporary aortic root deformation did not result in adverse clinical outcomes, and the patient made an uneventful recovery without need for permanent pacemaker implantation.

FIG. 4.3

Initial Valve Position.

Valve implantation was initiated with the distal valve edge ( arrowhead ) positioned 4 mm below the aortic annulus ( arrow ) (Online ).

FIG. 4.4

Valve Descent Into the Ventricle.

The valve descended into the ventricle during deployment, with the distal valve edge ( arrowhead ) positioned 24 mm below the aortic annulus ( arrow ) (Online ).

FIG. 4.5

Intussusception of the Aortic Annulus Into the Aorta.

Attempts to pull the valve proximally resulted in intussusception of the aortic annulus into the aorta, with deformation of the aortic root anatomy and continued severe aortic regurgitation ( arrowhead ) (Online ).

FIG. 4.6

Final Valve Position.

Final valve position with the distal valve edge ( arrowhead ) positioned 12 mm below the aortic annulus ( arrow ) (Online ).

This case highlights the need for new-generation retrievable and repositionable valves with improved control of positioning.

Conservative Management and Resolution of a Contained Rupture of Aortic Annulus Following Transcatheter Valve Replacement

Vijayakumar Subban, MBBS, MD, DM
Alexander Incani, MBBS
Andrew Clarke, MBBS
Constantine Aroney, MBBS, MD
Gregory M. Scalia, MBBS, MMSc
James A. Crowhurst, BSc
Owen Christopher Raffel, MBChB
Darren L. Walters, MBBS, MPhil

An 87-year-old woman with symptomatic severe aortic stenosis, logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) of 20.94%, and Society of Thoracic Surgeons estimated surgical mortality of 27.4%, underwent transcatheter aortic valve implantation (TAVI). Her transesophageal echocardiogram (TOE) showed a valve area of 0.7 cm 2 (peak velocity: 5.3 m/s), an annular diameter of 19 mm, and good left ventricular systolic function. The computed tomography aortogram showed heavily calcified aortic root, leaflets, and annulus ( Fig. 4.7 A–C), a descending thoracic aortic aneurysm, and small-caliber access vessels. The total volume of aortic leaflet calcium was 1444 mm 3 . The annulus transverse diameters were a minimum of 20 mm and a maximum of 23 mm, the perimeter was 63 mm, and the area was 290 mm 2 (3mensio valves, Pie Medical Imaging BV, Bilthoven, the Netherlands). The patient underwent TAVI via the transaortic root with a 23-mm Edwards SAPIEN XT valve (Edwards Lifesciences, Irvine, California). The immediate postdeployment TOE and aortogram showed an expanding hematoma of the posterior aortic root below the left main coronary artery ( Fig. 4.7 D–E). There was no pericardial effusion or hemodynamic compromise; hence, she was managed conservatively with local digital compression, packing of the mediastinal space with surgical sponges, reversal of anticoagulation, and lowering of systolic blood pressure. She was monitored on the table for 1 h. There was no further expansion of the hematoma ( Fig 4.7 F–G). The packing was removed and the sternum closed. She was transferred to the postoperative ward. The patient remained stable and serial echocardiograms showed resolution of the hematoma ( Fig. 4.7 H).

FIG. 4.7

Developments of Contained Aortic Annulus Rupture During Transcatheter Aortic Valve Implantation ( TAVI ) and Its Resolution With Conservative Management.

Computed tomography aortogram with 3mensio (Pie Medical Imaging BV, Bilthoven, the Netherlands) three-dimensional reconstruction (A), fluoroscopy (B), and transesophageal echocardiogram (TOE) (C) showing extensive aortic annular and outflow tract calcification ( asterisk ). (D) Aortogram revealing contained rupture below the left main coronary artery. (E) to (G) TOE in esophageal long axis view showing aortic root hematoma at various time intervals. (H) Follow-up transthoracic echocardiogram in parasternal long axis view showing resolved hematoma ( arrow ).

Annular rupture is a catastrophic complication of TAVI that occurs in 0.1% to 1% of the patients undergoing this procedure. Extensive annular, leaflet, and aortic calcification and implantation of oversized valve prosthesis predispose individuals to rupture, which has exclusively been reported with balloon-expandable prosthesis. Careful evaluation of the severity of the calcification and selecting an appropriately sized self-expanding valve in patients with extensive calcification might prevent this serious complication. Intraprocedural TOE may be of great value in the timely recognition of this serious adverse event. Frank rupture results in immediate tamponade and requires urgent surgical intervention. In cases with a transaortic approach where the sternum is open, a contained rupture may be managed with a conservative wait-and-watch policy. ,


  • 1. Hayashida K, Bouvier E, Lefèvre T, et. al.: Potential mechanism of annulus rupture during transcatheter aortic valve implantation.Catheter Cardiovasc Interv 2013; 82: pp. E742-E746. doi:10.1002/ccd.24524. [Epub 2013 Jun 25.]

  • 2. Stortecky S, Buellesfeld L, Wenaweser P, Windecker S: Transcatheter aortic valve implantation: prevention and management of complications.Heart 2012; 98: pp. iv52-64.

  • 3. Généreux P, Reiss GR, Kodali SK, Williams MR, Hahn RT: Periaortic hematoma after transcatheter aortic valve replacement: description of a new complication.Catheter Cardiovasc Interv 2012; 79: pp. 766-776.

Coronary Ostia Stenosis After Transcatheter Aortic Valve Implantation

Rodrigo Bagur, MD
Eric Dumont, MD
Daniel Doyle, MD
Eric Larose, DVM, MD
Jerôme Lemieux, MD
Sébastien Bergeron, MD
Sylvie Bilodeau, MD
Olivier F. Bertrand, MD, PhD
Robert De Larochellière, MD
Josep Rodés-Cabau, MD

A frail 85-year-old woman with symptomatic severe aortic stenosis was evaluated for transcatheter aortic valve implantation (TAVI). The Society of Thoracic Surgeons risk score and the logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) were 7.2% and 13.3%, respectively. Based on her extreme frailty and severe chronic kidney disease, the patient was considered nonsuitable for conventional surgery. Cardiac computed tomography and coronary angiography are shown in Fig. 4.8 . Because of the patient’s calcified and small (<7 mm) iliofemoral arteries, the procedure was performed by transapical approach. A 26-mm Edwards SAPIEN valve (Edwards Lifesciences, Irvine, California) was successfully implanted, although the valve was situated in a high position with respect to the aortic annulus (Online ). Twenty-four hours after TAVI, the patient had chest pain with transient ST-segment changes. A coronary angiography showed significant stenosis of the left main coronary artery (LMCA) and right coronary artery (RCA) ostia secondary to the displacement of the calcified native aortic leaflets toward the coronary ostia ( Fig. 4.9 A–B, Online and ). Percutaneous coronary intervention was successfully performed in both LMCA and RCA ostia ( Fig. 4.9 C–D, Online and ). A predischarge cardiac computed tomography and echocardiography are shown in Fig. 4.10 and Online , respectively. At 6-month follow-up the patient was in functional class II without cardiovascular events.

FIG. 4.8

Baseline Computed Tomography and Coronary Angiography.

(A) Computed tomography image showing the severity of aortic valve calcification (left coronary leaflet [ LCL ], right coronary leaflet [ RCL ]). (B) Computed tomography image showing the distance ( red lines ) between the insertion of the aortic leaflets and the origin of the left main coronary artery ( white arrows ). The distance between the insertion of the aortic leaflets and the origin of the right coronary artery was 11.5 mm. (C) Left coronary angiography showing the absence of left main coronary artery disease. (D) Right coronary angiography showing a moderate lesion (34% diameter stenosis by quantitative coronary angiography) at the origin of the right coronary artery.

FIG. 4.9

Coronary Angiography at 24 h After Transcatheter Aortic Valve Implantation.

Coronary angiography images showing significant stenosis ( thin arrows ) of the left main coronary artery (LMCA) (A) and right coronary artery (RCA) (B) ostia secondary to the displacement of the calcified native aortic leaflets ( thick arrows ) toward the coronary ostia. Coronary angiography images after percutaneous coronary intervention and stent implantation showing the absence of residual stenosis ( thin arrows ) at the LMCA (C) and RCA (D) ostia. The distance between the LMCA and RCA ostia and the struts of the valve were 1.89 mm and 1.29 mm, respectively. The transcatheter aortic valve implantation procedure and immediate echocardiographic results are shown in Online . Coronary angiography and intervention are shown in Online .

FIG. 4.10

Computed Tomography at Hospital Discharge.

(A and B) Cardiac computed tomography images of the Edwards SAPIEN valve and the two coronary stents ( thick arrows ) through the struts of the Edwards SAPIEN valve stent; thin arrows highlight the calcified native aortic leaflets. (C) Three-dimensional reconstruction of the Edwards SAPIEN valve with the two coronary stents ( thick arrows ) through the struts of the valve. A complementary transthoracic echocardiogram is shown in Online .

LMCA stenosis is a potential complication of TAVI. , This case shows that this complication can affect the two coronary ostia and become clinically evident in the subacute phase after TAVI. It also supports the feasibility of percutaneous coronary intervention through the struts of the implanted valve. The presence of a bulky calcified valve has been recognized as a risk factor for LMCA stenosis after TAVI, especially in those cases with a short distance (<8 mm) between the aortic leaflets and the coronary ostia. , In these cases, dye injection at the time of balloon valvuloplasty might be useful to determine the relation of the extended leaflets to coronary ostia.


  • 1. Rodés-Cabau J, Dumont E, De Larochellière R, et. al.: Feasibility and initial results of percutaneous aortic valve implantation including selection of the transfemoral or transapical approach in patients with severe aortic stenosis.Am J Cardiol 2008; 102: pp. 1240-1246.

  • 2. Webb JG, Chandavimol M, Thompson CR, et. al.: Percutaneous aortic valve implantation retrograde from the femoral artery.Circulation 2006; 113: pp. 842-850.

  • 3. Kapadia SR, Svensson L, Tuzcu EM: Successful percutaneous management of left main trunk occlusion during percutaneous aortic valve replacement.Catheter Cardiovasc Interv 2009; 73: pp. 966-972.

  • 4. Akhtar M, Tuzcu EM, Kapadia SR, et. al.: Aortic root morphology in patients undergoing percutaneous aortic valve replacement.J Thorac Cardiovasc Surg 2009; 137: pp. 950-956.

Cutaneopericardial Fistula After Transapical Approach for Transcatheter Aortic Valve Replacement

Karthiek Narala, MD
Sandeep Banga, MD
Sajjan Gayam, BS
Sudhir Mungee, MD

A 77-year-old man with severe aortic stenosis, previous coronary artery bypass graft, recurrent infective endocarditis, and chronic Q fever (taking hydroxychloroquine and doxycycline) underwent a transcatheter aortic valve replacement (TAVR) by the transapical (TA) approach via left thoracotomy. A 29-mm Edwards SAPIEN XT valve (Edwards Lifesciences, Irvine, California) was successfully deployed using the Ascendra 2 delivery system (Edwards Lifesciences). Purse-string sutures were placed at the left ventricular (LV) apex. Postprocedure development of a hemorrhagic pericardial effusion necessitated surgical reexploration; bleeding from the LV apex was controlled with placement of pledgeted purse-string sutures. Further postprocedure recovery was complicated by gram-negative pneumonia ( Serratia marcescens and Klebsiella pneumoniae ) that improved with levofloxacin.

Two months later, the patient complained of swelling above the incision site. Chest computed tomography demonstrated a hematoma that was managed conservatively ( Fig. 4.11 A).

FIG. 4.11

Presentation and Imaging.

(A) Computed tomography (CT) of the chest shows a hematoma of 73.4 × 50.3 mm in the left chest wall. (B) Left lateral chest wall demonstrates a healed thoracotomy scar and a necrotic 1- × 2-cm abscess along the anterior axillary line ( arrow ). (C) CT showing extravasation of contrast from the left ventricular cavity into the pseudoaneurysm and fistula formation extending to the chest wall ( arrow ). (D) CT showing the contrast in left ventricle draining in the abscess under the chest wall of 86.1 × 52.9 mm.

Four months after TAVR, the patient developed a necrotic skin lesion with wound drainage ( Fig. 4.11 B). Computed tomography showed extravasation of contrast through the LV apex into the surrounding soft tissue and a fluid collection within the chest wall consistent with an LV apical pseudoaneurysm and cutaneopericardial fistula ( Fig. 4.11 C–D). The patient underwent a left thoracotomy with rib resection, removal of the epicardial pacemaker lead, fistula repair, and replacement of the pledgets ( Fig. 4.12 A–C). Cultures from the surgical specimen demonstrated no growth. The patient received prophylactic vancomycin and was subsequently discharged.

FIG. 4.12

Surgical Evacuation.

(A) Left lateral view three-dimensional reconstruction of computed tomography images showing the connection ( arrow ) between the left ventricle and the pseudoaneurysm. (B) Fistula opening ( arrow ) in the chest wall during surgical excision. (C) Excised pseudoaneurysm and clot, approximately 45 mm.

Unusual complications of a TA approach, including ventricular septal defect, apical pseudoaneurysm, and LV rupture, have been reported. In TAVR, TA access site infections have an occurrence rate of 3.2%. One of the rarest complications is cutaneopericardial fistula, with only one reported case; pledgeted sutures were attributed as the source of infection.

To our knowledge, this is the first reported case in the United States. The immunocompromised status of our patient (due to long-term hydroxychloroquine) possibly increased the risk of infection. Furthermore, chronic doxycycline therapy possibly obscured the search for causative organisms. Potential sources of infection were the presence of an epicardial pacemaker lead, need for surgical reexploration, and the development of nosocomial pneumonia. Prior reports have implicated BioGlue (CryoLife Inc., Kennesaw, Georgia) as a source of infection ; however, it was not used in this case.

Cutaneopericardial fistula is a rare but clinically significant complication of the TA approach in TAVR. Infection control, meticulous procedural technique, heightened clinical suspicion, early recognition, and prompt treatment are all important measures in reducing adverse clinical outcomes.


  • 1. Al-Attar N, Ghodbane W, Himbert D, et. al.: Unexpected complications of transapical valve implantation.Ann Thorac Surg 2009; 88: pp. 90-94.

  • 2. Baillot R, Fréchette E, Cloutier D, et. al.: Surgical site infections following transcatheter apical aortic valve implantation: incidence and management.J Cardiothorac Surg 2012; 7: pp. 122-127.

  • 3. Scheid M, Grothusen C, Lutter G, Petzina R: Cutaneo-pericardial fistula after transapical aortic valve implantation.Interact Cardiovasc Thorac Surg 2013; 16: pp. 558-559.

  • 4. Pasic M, Unbehaun A, Drews T, Hetzer R: Late wound healing problems after use of BioGlue for apical hemostasis during transapical aortic valve implantation.Interact Cardiovasc Thorac Surg 2011; 13: pp. 532-534.

Failed Valve-In-Valve Transcatheter Aortic Valve Implantation

Stefan Klotz, MD
Michael Scharfschwerdt, PhD
Doreen Richardt, MD
Hans H. Sievers, MD

In 2004, a 68-year-old man received aortocoronary bypass surgery and a 23-mm Hancock porcine bioprosthesis (Medtronic, Minneapolis, Minnesota). Six years later, in January 2011, cardiac reevaluation was performed due to progressive dyspnea. Invasive angiography showed open bypass grafts and severe stenosis of the porcine aortic bioprosthesis. Because of significant comorbidities, a 23-mm SAPIEN XT (Edwards Lifesciences, Irvine, California) transcatheter aortic valve implantation (TAVI) was performed as valve-in-valve. The procedure was uneventful. Initial angiography and echocardiography showed a good function of the valve with no insufficiency and a mean gradient of 20 mm Hg (Online ).

In March 2011, 3 months after the procedure, the patient was readmitted with cardiac decompensation. Reangiography showed open bypass grafts, but an invasive gradient of 50 mm Hg over the SAPIEN valve. Echocardiography confirmed the severe stenosis of the SAPIEN valve with a maximum gradient of 66 mm Hg, a mean of 43 mm Hg, and a valve opening area of 0.6 cm 2 . Because of the patient’s dyspnea, reoperation was scheduled after recompensation. In May 2011, both the SAPIEN valve and the 2004 implanted Hancock bioprosthesis were explanted ( Fig. 4.13 ) and replaced with a 21-mm Trifecta (St. Jude Medical, Inc., St. Paul, Minnesota) bioprosthesis. The postoperative course was uneventful.

FIG. 4.13

The Explanted 23-mm Hancock Bioprosthesis With the Implanted 23-mm SAPIEN Transcatheter Valve.

The arrowheads show the uneven commissures in the Hancock valve (Online ).

Postexplantation assessment of the valves showed the implanted 23-mm SAPIEN valve incompletely expanded within the stents of the 23-mm Hancock bioprosthesis. This leads to asymmetrical commissural distances and wrinkles of the leaflets ( Fig. 4.14 ). In vitro investigation of the valves under pulsatile conditions showed folding and uneven leaflet coaptation in the diastolic state and a severely limited opening of the valve in systole, with a visual orifice area of 0.54 cm 2 (Online ). Pressure gradients were 24.2 mm Hg (mean) and 42.2 mm Hg (maximum) at a cardiac output of 4.3 L/min. Even though TAVI shows promising results in high-risk patients, the concept of valve-in-valve in degenerated aortic bioprostheses is quite new. Reports successfully demonstrated the feasibility of this approach. However, experimental studies could show the rigidity of the bioprosthesis can constrain the TAVI valve and prevent full expansion of the stents. Because the inner diameter of a 23-mm Hancock bioprosthesis is only 19 mm, a circumferential part of 12.5-mm is missing to unfold the 23-mm Edwards SAPIEN transcatheter valve. This leads to uneven commissural distances that might affect leaflet coaptation and leaflet folding, which could severely restrict the opening of the valve. Our case emphasizes the difficulties of valve-in-valve TAVI for degenerated aortic bioprosthesis. These procedures should be done with caution.

FIG. 4.14

In Vitro Assessment in Diastole and Systole.

(A) Diastole. (B) Systole (Online ).


  • 1. Lefèvre T, Kappetein AP, Wolner E, et. al., for the PARTNER EU Investigator Group: One year follow-up of the multi-centre European PARTNER transcatheter heart valve study.Eur Heart J 2011; 32: pp. 148-157.

  • 2. Walther T, Falk V, Dewey T, et. al.: Valve-in-a-valve concept for transcatheter minimally invasive repeat xenograft implantation.J Am Coll Cardiol 2007; 50: pp. 56-60.

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  • 4. Azadani AN, Jaussaud N, Matthews PB, Ge L, Chuter TA, Tseng EE: Transcatheter aortic valves inadequately relieve stenosis in small degenerated bioprostheses.Interact Cardiovasc Thorac Surg 2010; 11: pp. 70-77.

Gluing an Aortic Perforation During Transcatheter Aortic Valve Replacement: An Alternative Treatment for Annular Rupture?

Nicolas Piliero, MSc
Fréderic Thony, MD
Gerald Vanzetto, MD, PhD
Gilles Barone-Rochette, MD, PhD

A 96-year-old man was referred to our cardiology center for a transcatheter aortic valve replacement (TAVR). Preimplantation transthoracic echocardiography showed preserved ejection fraction, mean transvalvular pressure gradient at 46 mm Hg, aortic valve area of 1 cm 2 , and maximal aortic jet velocity at 4.1 m/s, confirming severe aortic stenosis. Aortic annulus diameter was 25 mm as measured by transesophageal echocardiography, and its surface was 671 mm 2 as observed with three-dimensional multidetector computed tomography ( Fig. 4.15 A–B). A 29-mm SAPIENS XT valve (Edwards Lifesciences, Irvine, California) was implanted using left transfemoral access. During prosthetic valve deployment, contrast extravasation into the pericardium occurred ( Fig. 4.15 C), causing cardiac shock and pericardial tamponade demonstrated by transthoracic echocardiography. Percutaneous pericardiocentesis and fluid infusion were immediately performed, allowing hemodynamic stabilization. Tissue glue composed of a 1/1 mixture of N -butyl-2-cyanoacrylate (Histoacryl) and Lipiodol (B. Braun, Melsungen, Germany) was injected into the perforation using a Progreat microcatheter (Terumo Corporation, Tokyo, Japan) introduced through a 6F Amplatz left guiding catheter (Medtronic, Dublin, Ireland) ( Fig. 4.15 D). This successfully stopped the pericardial effusion ( Fig. 4.15 E) and allowed the procedure to be completed without further complications. The patient was discharged 5 days after the valve deployment.

FIG. 4.15

Computed Tomography and Angiography Imagery Before and During Transcatheter Aortic Valve Replacement Procedure.

(A and B) Preoperative computed tomography showed massive calcification on the aortic valve annulus and left anterior leaflet ( yellow arrow ). (C) A severe contrast extravasation ( yellow arrows ) was identified during angiography after transcatheter aortic valve implantation. (D) Tissue glue was injected into the perforation with a microcatheter. (E) Severe contrast extravasation was stopped successfully by liquid embolization mixtures.

Aortic rupture occurs in about 1% of all TAVR implantations. , Potential causes include radial forces during valve deployment inducing tissue overdistention along with calcification of the annulus and/or valve leaflets. Depending on the severity and location of the perforation, treatment can include cardiac surgery, isolated percutaneous pericardiocentesis, or a conservative strategy. N -butyl-2-cyanoacrylate is a tissue glue that has the capacity to harden immediately when in contact with blood. The adjunction of oily radiopaque substance (Lipiodol) delays polymerization and allows radiopacity. Thus we report here a novel potential treatment for aortic rupture during TAVR by an endovascular approach.

▪ Acknowledgment

The authors thank Raphaëlle-Ashley Guerbaai for editorial support.


  • 1. Pasi M, Unbehaun A, Buz S, Drews T, Hetzer R: Annular rupture during transcatheter aortic valve replacement: classification, pathophysiology, diagnostics, treatment approaches, and prevention.JACC Cardiovasc Interv 2015; 8: pp. 1-9.

  • 2. Möllmann H, Kim WK, Kempfert J, Walther T, Hamm C: Complications of transcatheter aortic valve implantation (TAVI): how to avoid and treat them.Heart 2015; 101: pp. 900-908.

  • 3. Stoesslein F, Ditscherlein G, Romaniuk PA: Experimental studies on new liquid embolization mixtures (Histoacryl-Lipiodol, Histoacryl- Pan-thopaque).Cardiovasc Intervent Radiol 1982; 5: pp. 264-267.

Left Anterior Descending Coronary Artery Obstruction Associated With an Apical Suture After Transcatheter Aortic Valve Replacement

Yutaka Koyama, MD
Masanori Yamamoto, MD
Yasuhide Okawa, MD
Takahiko Suzuki, MD

An 88-year-old woman with symptomatic severe aortic stenosis was referred to our center. She was considered to be at high risk for surgical aortic valve replacement because of comorbidities and advanced age. Our heart team opted for transcatheter aortic valve replacement via transapical access because of issues with the peripheral artery. A pair of pledgeted purse-string sutures was placed around the apex via left anterolateral thoracotomy at the sixth intercostal space. A 23-mm SAPIEN XT prosthesis (Edwards Lifesciences, Irvine, California) was successfully implanted in the target position. However, the recovery of blood pressure was poor, and hypokinetic motion of the apex was noted in the surgical view. Aortography showed trivial aortic regurgitation without obstruction of the left coronary artery orifice ( Fig. 4.16 A). Additionally, selective angiography of the left coronary artery revealed obstruction of the middle part of left anterior descending artery (LAD) ( Fig. 4.16 B), whereas previous coronary angiography did not show significant stenosis. The sutures were more than 10 mm away from the LAD in direct vision, which was confirmed in postprocedural computed tomography ( Fig. 4.16 C). After removing one of the sutures, which was relatively close to the LAD, the obstruction of the LAD improved slightly but remained significant. Therefore a vasodilator was repeatedly infused into the LAD, and the flow of the LAD completely recovered ( Fig. 4.16 D).

FIG. 4.16

Angiography and Postprocedural Computed Tomography.

(A) Aortography shows the target position of the prosthetic valve and the patency of the left coronary orifice. (B) Left coronary angiography shows narrowing of the left anterior descending artery (LAD) after the sheath is removed and the apical sutures are snared with tourniquets. (C) Postprocedural computed tomography shows that the apical sutures are away from the LAD. (D) Angiography shows complete recovery of LAD flow after infusion of a vasodilator.

Obstruction of the LAD in the present case was induced by muscle tension and deformation around the apical sutures. In addition to the removal of the apical suture, selective vasodilator infusion for the obstructed LAD might be effective. The present unique case revealed one of the potential etiologies of LAD obstruction after transapical transcatheter aortic valve replacement.

Left-to-Right Interventricular Shunt as a Late Complication of Transapical Aortic Valve Implantation

Pierre Massabuau, MD
Nicolas Dumonteil, MD
Pierre Berthoumieu, MD
Bertrand Marcheix, MD, PhD
David Duterque, MD
Gérard Fournial, MD
Didier Carrié, MD, PhD

An 86-year-old man was referred to our institution for a symptomatic severe aortic stenosis (New York Heart Association [NYHA] functional dyspnea class III; indexed effective orifice area [EOA] 0.3 cm 2 /m 2 ; mean gradient [MG] 54 mm Hg; left ventricular ejection fraction [LVEF] 56%). He had a history of dyslipidemia, prostate cancer, and coronary artery bypass graft (saphenous vein graft on left anterior descending coronary artery [LAD] and right coronary artery) 26 years previously.

A transcatheter aortic valve implantation (TAVI) was proposed because this patient was considered a high surgical risk candidate (logistic EuroSCORE [European System for Cardiac Operative Risk Evaluation] 28%, Society of Thoracic Surgeons score 7%). A transapical approach was chosen, because both the iliofemoral and subclavian arteries were not suitable for transarterial access. The aortic annulus measured by transesophageal echocardiography was 22.6 mm.

The procedure was performed under general anesthesia, through a left minithoracotomy, as previously described. A 26-mm Edwards SAPIEN valve (Edwards Lifesciences, Irvine, California) was implanted under fluoroscopy and transesophageal echocardiography guidance with good procedural outcome. The postimplantation period was marked by an increase of cardiac troponin I (peak, 12.9 ng/mL) and a transient renal failure. At discharge (day 10), the patient was in NYHA functional class II and heart sounds were normal. Transthoracic echocardiography (TTE) showed LVEF at 63%, prosthesis MG at 11 mm Hg, indexed EOA at 0.91 cm 2 /m 2 , stable mild paravalvular leak, and pulmonary artery systolic pressure at 47 mm Hg.

Clinical and TTE data were similar at 1-month and 6-month follow-up. At 1-year follow-up, the patient declined to NYHA functional class III. He described no chest pain since his last visit. Clinical examination revealed a loud continuous systolic and diastolic murmur. There was no change of the electrocardiogram. The TTE revealed a moderate enlargement of the right ventricular cavity. The apical part of the interventricular septum appeared less echogenic than the rest of the myocardium ( Fig. 4.17 ). Color Doppler showed a continuous left-to-right flow through the apical part of the interventricular septum with a Doppler peak systolic gradient of 89 mm Hg ( Fig. 4.18 A–B). The LVEF, prosthetic mean gradient, and indexed EOA were 63%, 11 mm Hg, and 0.90 cm 2 /m 2 , respectively. Pulmonary artery systolic pressure was 65 mm Hg. An echocardiographic contrast agent (SonoVue, Bracco Imaging, Milan, Italy) failed to reach the apex of the right ventricle. It seemed to be “washed” by the shunt flow ( Fig. 4.19 , Online ). After a few cardiac cycles, contrast agent appeared into the left cardiac cavities and at last into the right ventricle apex through the septal communication.

FIG. 4.17

Two-Dimensional Transthoracic Echocardiography Apical View of the Left Ventricle and Right Ventricle.

The echogenicity of the apical segment ( white arrow ) of interventricular septum is less pronounced than the basal and medial segments. The right ventricle apex is enlarged.

FIG. 4.18

Color Doppler Imaging of the Left-to-Right Flow.

(A) Color Doppler imaging of the left-to-right flow through the apical part ( white arrow ) of the interventricular septum. (B) Continuous-wave Doppler of the left-to-right flow through the apical part of the interventricular septum. GP , maximal pressure gradient; Vit , peak velocity.

FIG. 4.19

Intravenous Injection of an Echocardiographic Contrast Agent.

During the first cardiac cycles, microbubbles cannot reach the right ventricular apex because of “washing effect” of left-to-right flow (Online ).

After considering the age and will of the patient, a moderate cognitive impairment, a progressive prostate cancer, and despite the worsening of his functional status, we decided against any invasive treatment.

Various transapical TAVI complications have been described, mostly observed during initial procedure or short-term follow-up. ,

In this case, we can reasonably argue that puncture through the septum at the time of the procedure did not cause this late septal defect, because we can expect that it would have been observed before discharge or during initial follow-up. It is likely that this complication was caused by late rupture of scar tissue due to periprocedural injury. The potential mechanisms of this injury could be (1) occlusion of the distal LAD or a side branch by the purse-string suture, resulting in a periprocedural myocardial infarction, or (2) a pressure necrosis caused by an apical puncture and then an insertion of the sheath too close to the distal septum.

To our best knowledge, this is the first report of late apical interventricular communication after transapical TAVI. Considering the possible causes just discussed, periprocedural echocardiographic guidance of the left ventricle apical puncture and subsequent sheath insertion could be proposed to prevent this complication. Particular attention should also be given to the location of the distal LAD before making the purse-string suture.

This case emphasizes the role of systematic regular follow-up to detect late complications after such procedures. It might also improve our awareness of the wide range of potential complications of TAVI.


  • 1. Ye J, Cheung A, Lichtenstein SV, et. al.: Transapical aortic valve implantation in humans.J Thorac Cardiovasc Surg 2006; 131: pp. 1194-1196.

  • 2. Al-Attar N, Ghodbane W, Himbert D, et. al.: Unexpected complications of transapical aortic valve implantation.Ann Thorac Surg 2009; 88: pp. 90-94.

  • 3. Tzikas A, Schultz C, Piazza N, et. al.: Perforation of the membranous interventricular septum after transcatheter aortic valve implantation.Circ Cardiovasc Interv 2009; 2: pp. 582-583.

Novel Percutaneous Apical Exclusion of a Left Ventricular Pseudoaneurysm After Complicated Transapical Transcatheter Aortic Valve Replacement

Soraya Merchan, MD
Chi-Hion Li, MD
Francisco Javier Martinez, MD
Chad Kliger, MD
Vladimir Jelnin, MD
Gila Perk, MD
Derek Brinster, MD
Itzhak Kronzon, MD
Carlos E. Ruiz, MD, PhD

A 78-year-old woman with a history of coronary artery bypass grafting underwent transapical transcatheter aortic valve replacement with a SAPIEN XT (Edwards, Irvine, California) prosthesis that was complicated by an apical left ventricular pseudoaneurysm (LVPA). Unsuccessful attempts at closure included percutaneous retrograde transaortic placement of a 12-mm Amplatzer ventricular septal defect occluder (St. Jude Medical, Minneapolis, Minnesota) and surgical CorMatrix (CorMatrix Cardiovascular, Roswell, Georgia) patch repair on cardiopulmonary bypass, both with residual expanding and/or recurrent LVPA. A novel transcatheter approach was performed to exclude the left ventricular apex and flow into the LVPA. Using computed tomography–fluoroscopy fusion imaging (HeartNavigator, Philips, Best, the Netherlands), percutaneous transapical access was performed adjacent to the true apical site of the LVPA. The 26-mm Amplatzer septal and 35-mm Amplatzer cribriform occluders were positioned and deployed with the distal disks overlapping, excluding the apical cavity, and the proximal disks positioned on the epicardial surface. Residual flow was noted through the polyester fabric of the devices, and an additional percutaneous transapical access through the LVPA exit site was performed with placement of a 4F sheath. Three 0.052-inch 10 × 15-mm coils (Cook Medical, Bloomington, Indiana) soaked in thrombin were placed within the excluded apical segment. Echocardiography revealed no further flow into the LVPA, with increased echogenicity of the sac suggesting thrombosis. Computed tomography performed before discharge confirmed total occlusion of the LVPA with complete apical exclusion ( Fig. 4.20 ).

FIG. 4.20

Computed Tomographic Angiography (CTA) With Three-Dimensional (3D) Volume-Rendered Images and Fluoroscopy With CT Fluoroscopy Fusion Imaging Illustrate This Novel Percutaneous Approach.

(A) to (C) CTA with 3D volume-rendered images. (D) to (F) Fluoroscopy with computed tomography–fluoroscopy fusion imaging. (A) After unsuccessful surgical patch ( yellow arrows ) closure, a large recurrent left ventricular pseudoaneurysm ( LVPA ) was identified. (B) Complete apical exclusion was next noted with the placement of two overlapping Amplatzer occluders (St. Jude, Minneapolis, Minnesota) adjacent to the true apical site of the LVPA, and residual flow was identified. (C) Percutaneous transapical placement of three 0.052-inch 10 × 15-mm coils (Cook Medical, Bloomington, Indiana) soaked in thrombin were placed into the excluded apical space ( asterisks ) with total occlusion of the LVPA shown. (D) A percutaneous transapical sheath can be identified within the excluded apical segment created by Amplatzer devices; contrast injection revealed flow through the device. (E) Placement of coils with the aid of fusion imaging can be seen, and (F) final left ventriculography confirmed complete apical exclusion and no residual contrast into the LVPA. White arrows indicate residual leak.

Apical left ventricular pseudoaneurysm is an infrequent complication after transapical transcatheter aortic valve replacement (TAVR). They have been traditionally surgically repaired ; however, patients who undergo TAVR have high operative risk with multiple comorbidities, increasing significantly the risk of surgical repair. Some cases of percutaneous closure have been reported, but the experience with this procedure is limited. We describe the first case of percutaneous closure guided by a novel system of image fusion using computed tomography and fluoroscopy.


  • 1. Collier P, Phelan D, Soltesz E, Aljaroudi W: Left ventricular pseudoaneurysm: “to-and-fro” flow.J Am Coll Cardiol 2013; 61: pp. 896.

  • 2. Acharya D, Nagaraj H, Misra VK: Transcatheter closure of left ventricular pseudoaneurysm.J Invasive Cardiol 2012; 24: pp. E111-E114.

Percutaneous Management of Mitral Perforation During Transcatheter Aortic Valve Replacement

Asma Bourezg, MD
Cyril Prieur, MD
Gérard Finet, MD, PhD
Gilles Rioufol, MD, PhD

A New York Heart Association functional class III symptomatic 90-year-old man with severe aortic stenosis had a 519-mm 2 annulus aortic area estimated by computed tomography (sinus of Valsalva 710 mm 2 and sinotubular junction 540 mm 2 ) ( Fig. 4.21 A and A′). He underwent an uneventful femoral access transcatheter aortic valve replacement (26-mm Edwards SAPIEN 3, Edwards Lifesciences, Irvine, California) ( Fig. 4.21 B) and 1 h later experienced intractable cardiogenic shock with intense holosystolic murmur. By transesophageal echocardiography, aortic prosthesis showed no anomaly, and a massive mitral regurgitation by perforation of the mitral-aortic curtain was diagnosed ( Fig. 4.21 C [ arrow ] and C′). Mitral-aortic curtain calcifications were a posteriori thought to be causative ( Fig. 4.21 A′, arrow ). A rescue percutaneous repair was decided upon and, under transesophageal echocardiography control after transseptal catheterization, the mitral perforation could be crossed ( Fig. 4.21 D) with a 5F coronary hooked catheter (Bartorelli-Cozzi, Johnson & Johnson, New Brunswick, New Jersey) and a hydrophilic 0.035-inch wire. Using the standard technique, an 8-mm Amplatzer septal occluder (St. Jude Medical, St. Paul, Minnesota) was then successfully deployed across the anterior leaflet ( Fig. 4.21 D′ and E) and dramatically decreased the mitral regurgitation ( Fig. 4.21 E′). Mitral valve functioning was not significantly impaired ( Fig. 4.21 F and F′, Online ) by the plug, and no anterograde gradient was noted. Hemodynamics rapidly recovered, and inotropic support as well as the assisted ventilation could be stopped 6 h later. The patient was discharged 5 days later. Mild hemolytic anemia was observed during the first 6 months; this was corrected by episodic blood transfusions and ultimately resolved. At 2-year-follow-up, the patient is doing well without aortic or mitral valve abnormalities.

FIG. 4.21

Images of Mitral Aortic Curtain Perforation Management.

(A and A′) Three-dimensional computed tomography showing aortic stenosis and calcification developing on mitral-aortic curtain (A′, arrow ). (B) Final angiogram of the transcatheter aortic valve replacement. (C and C′) Transesophageal echocardiography (TEE) showing severe mitral regurgitation (MR) by perforation of the mitral-aortic curtain (C, arrow ). (D and D′) Percutaneous management with an 8-mm Amplatzer septal occluder (St. Jude Medical, St. Paul, Minnesota). (E and E′) Postprocedure TEE showing the plug and near disappearance of the MR. (F and F′) Three-dimensional TEE of the mitral valve in systole (F) and diastole (F′) (Online ).

The mitral apparatus is vulnerable and could be badly impaired in transcatheter aortic valve replacement patients. Albeit rare, mitral perforation is a complication that physicians should be aware of because percutaneous management may be lifesaving.

Percutaneous Treatment of Severe Aortic Insufficiency in a Patient With a Left Ventricular Assist Device: Friend or Foe?

Michael Zacharias, DO
Ravi Dhingra, MD, MPH

A 29-year-old man with congenitally corrected transposition of the great arteries underwent implantation of a HeartMate II left ventricular assist device (LVAD) (Thoratec Corp., Pleasanton, California) as a result of worsening systemic right ventricular failure and New York Heart Association class IV symptoms, as a bridge to transplant. After 6 months, he presented with atrial arrhythmias and abdominal bloating. Transthoracic echocardiogram was repeated and showed severe continuous aortic insufficiency, which previously had been mild. The patient was referred to the cardiac catheterization laboratory for a hemodynamic assessment and possible use of an Amplatzer septal occluder (AGA Medical, Plymouth, Minnesota) for closure of his aortic valve. Right-sided heart catheterization hemodynamics showed a right atrial pressure of 16 mm Hg, pulmonary artery pressure of 49/22 mm Hg, and pulmonary wedge pressure of 18 mm Hg. Via the right femoral artery, a 30-mm Amplatzer atrial septal cribriform device was advanced across the aortic valve and positioned under transesophageal echocardiogram guidance. To-and-fro motion was performed to test stability, and the device appeared secure with minimal residual aortic insufficiency. The device was released and stayed in a stable position, which was also confirmed by chest x-ray ( Fig. 4.22A ). This technique has been previously described with success through a femoral and subclavian approach. The following day, a chest x-ray showed that the device had migrated into the left ventricle ( Fig. 4.22 B). An emergent computed tomography scan of the chest was performed that showed that the occluder device had migrated to the orifice of the LVAD inflow cannula ( Fig. 4.23 ). The LVAD speed was reduced to prevent the device from completely obstructing the LVAD inflow cannula. Coincidentally, a donor heart became available on the same night, and the patient successfully received the transplant without any complications. Although a septal occluder device has previously been described to improve aortic insufficiency; it does so with potential risk.

FIG. 4.22

Chest X-Ray.

The chest x-ray shows (A) stable position postdeployment and (B) migration the following day. Red arrows indicate septal occluder position.

FIG. 4.23

Computed Tomography (CT) Scan of the Chest.

CT scan of the chest shows the Amplatzer septal occluder ( red arrow ) partially overlying the left ventricular assist device inflow cannula.


  • 1. Parikh KS, Mehrotra AK, Russo MJ, et. al.: Percutaneous transcatheter aortic valve closure successfully treats left ventricular assist device– associated aortic insufficiency and improves cardiac hemodynamics.JACC Cardiovasc Interv 2013; 6: pp. 84-89.

  • 2. Grohmann J, Blanke P, Benk C, Schlensak C: Trans-catheter closure of the native aortic valve with an Amplatzer Occluder to treat progressive aortic regurgitation after implantation of a left-ventricular assist device.Eur J Cardiothorac Surg 2011; 39: pp. e181-e183.

Perforation of Anterior Mitral Leaflet Due to Mechanical Stimulation Late After Transcatheter Aortic Valve Replacement

Mizuki Miura, MD
Akihiro Isotani, MD
Kenichiro Murata, MD
Tomohiro Kawaguchi, MD
Masaomi Hayashi, MD
Yoshio Arai, MD
Shinichi Shirai, MD
Michiya Hanyu, MD
Kenji Ando, MD

An 82-year-old man underwent transcatheter aortic valve replacement (TAVR) for symptomatic severe aortic stenosis (AS) using a 23-mm balloon-expandable SAPIEN XT valve (Edwards Lifesciences, Irvine, California) deployed via a transapical approach ( Fig. 4.24 A). He was referred to our center for dyspnea (New York Heart Association functional class IV) 6 months after TAVR. Transthoracic echocardiography revealed new mitral regurgitation from the middle of the anterior mitral leaflet (AML) to the posterior wall ( Fig. 4.24 B, Online ). Transesophageal echocardiography revealed perforation of the AML where it made contact with the bottom of the implanted valve ( Fig. 4.24 C–D, Online and ). He could not undergo open-heart surgery because of a history of coronary artery bypass surgery, poor general health, and frailty. Despite intensive heart failure treatment for a month, he died of progressive low-output syndrome and worsening renal failure. According to the results of autopsy, the AML had been perforated by mechanical stimulation from the implanted valve; however, mitral valve destruction by infectious endocarditis (IE) was not recognized macroscopically ( Fig. 4.24 E). Microscopically, well-defined disruption of elastic fiber in the mitral valve was found in elastica Masson stain, suggesting mechanical stimulation, rather than infectious endocarditis ( Fig. 4.24 F).

FIG. 4.24

Transcatheter Aortic Valve Replacement (TAVR), Transthoracic Echocardiography (TTE), Transesophageal Echocardiography (TEE), and Pathologic Images.

(A) A 23-mm SAPIEN XT deployed via a transapical approach. (B) TTE showing new mitral regurgitation (MR) ( arrow ) (Online ). (C) TEE showing perforation of the anterior mitral leaflet (AML) where it made contact with the bottom of the implanted valve ( arrow ) (Online ). (D) Three-dimensional TEE showing perforation of the AML and severe MR ( arrow ) (Online ). (E) Macroscopic findings showing the AML perforated by mechanical stimulation from the implanted valve ( arrow ). (F) Microscopic findings showing elastic fiber cut by mechanical stimulation ( arrow ). AML , anterior mitral leaflet; Ao , aorta; LA , left atrium; LV , left ventricle; LVOT , left ventricular outflow tract; XT , SAPIEN XT valve.

TAVR is an alternative option for patients with severe AS considered inoperable or at high risk for surgical aortic valve replacement. Although the number of TAVR procedures has rapidly increased worldwide, there are few reports about perforation of the AML because of mechanical stimulation late after TAVR without IE. It is important to note this point and avoid low implantation during the TAVR procedure.

Severe Valve Deformation Following Cardiopulmonary Resuscitation in a Patient With a Transcatheter Aortic Valve

Creighton W. Don, MD, PhD
James M. McCabe, MD
Corinne L. Fligner, MD

An 87-year-old patient with severe aortic stenosis underwent transapical transcatheter aortic valve replacement with a 26-mm Edwards SAPIEN valve (Edwards Lifesciences, Irvine, California). Preoperative imaging was notable for severe asymmetric calcification along the posterolateral aspect of the left ventricular outflow tract (LVOT) involving the intravalvular fibrous curtain ( Fig. 4.25 ). The aortic annulus area measured 430 mm 2 by computed tomographic imaging, allowing for 23% oversizing. Valve deployment was appropriate but was remarkable for moderate paravalvular regurgitation at the site of the LVOT calcification. The valve was redilated with an additional 1 mL of fluid added to the delivery balloon, modestly reducing the regurgitation. The patient recovered well and experienced mild heart failure symptoms. On hospital day 4, the patient experienced a cardiac arrest and underwent 48 min of cardiopulmonary resuscitation without return of spontaneous circulation. Autopsy demonstrated that the SAPIEN valve was crushed, with deformation of the valve at the site of the LVOT calcium ( Fig. 4.26 , Online ). Such severe valve distortion would have significantly impaired leaflet coaptation and function, and it is likely that successful resuscitation was impossible once the valve was crushed. The LVOT calcium caused significant paravalvular leak and likely contributed to valve deformation during chest compressions ( Fig. 4.27 , Online ). Care must be taken when providing cardiopulmonary resuscitation to patients with balloon-expandable transcatheter aortic valve prostheses, and follow-up imaging to evaluate valve deformation is crucial.

FIG. 4.25

Severe Calcification of the Left Ventricular Outflow Tract (LVOT).

Computed tomography angiogram showing severe calcification of the LVOT along the intravalvular fibrous curtain.

FIG. 4.26

Autopsy Images of the Transcatheter Valve After Cardiopulmonary Resuscitation.

(A) Crushed transcatheter valve shown from the aortic side. (B) Crushed transcatheter valve shown from the ventricular side (Online ). LVOT , left ventricular outflow tract.

FIG. 4.27

Left Ventricular Outflow Tract (LVOT) Calcium Deforming the Transcatheter Valve Frame.

Postmortem radiograph showing left ventricular outflow tract (LVOT) calcium deforming the transcatheter valve frame (Online ).


  • 1. Gunning PS, Vaughan TJ, McNamara LM: Simulation of self-expanding transcatheter aortic valve in a realistic aortic root: implications of deployment geometry on leaflet deformation.Ann Biomed Eng 2014; 42: pp. 1989-2001.

ST-Elevation Myocardial Infarction After Transcatheter Aortic Valve Replacement: Procedural Challenge and Catastrophic Outcome

Ahmed Harhash, MD
Julia Ansari, MD
Leonid Mandel, MD
Robert Kipperman, MD

An 82-year-old woman with severe aortic stenosis, 6 months posttranscatheter aortic valve replacement (TAVR) with a 29-mm CoreValve Evolut system (Medtronic, Minneapolis, Minnesota), presented with an anterior ST-segment elevation myocardial infarction. Coronary angiography (CA) using an extra-backup (EBU) 3.5 guide catheter (Medtronic, Minneapolis, Minnesota) via radial access was unfeasible because the stent frame interfered with the guide catheter. Using a 4.0 Judkins left guide catheter (Cordis, Fremont, California) via femoral access, left CA revealed complete occlusion of the distal left anterior descending coronary artery (LAD) ( Fig. 4.28 A). Percutaneous coronary intervention (PCI) using an EBU 3.5 catheter with deployment of a drug-eluting stent was successful ( Fig. 4.28 B). Balloon and guidewire were removed, but guide catheter recovery was not feasible because of its entrapment within the stent frame. Multiple maneuvers to retrieve the catheter failed and resulted in dissection of the left main coronary artery and the LAD ( Fig. 4.28 C–D). Surgical extraction of the catheter was recommended, but the patient and her family declined further intervention. With the catheter in place, the patient developed cardiogenic shock and her family requested withdrawal of care.

FIG. 4.28

Left Coronary Angiography and Ex Vivo Simulation.

(A) Left coronary angiography showing total occlusion of the distal left anterior descending coronary artery ( arrow ). (B) Left coronary angiography postpercutaneous coronary intervention and drug-eluting stent deployment ( arrow ). (C and D) Dissection of the left main and left anterior descending coronary arteries. (E) ( a ) Interrupted line showing guide catheter engagement into the left coronary ostium at an acute angle with the vertical axis of the stent frame. ( b ) Interrupted line showing crossing of the stent frame at a perpendicular angle. (F) Ex vivo simulation using an extra-backup 3.5 guide catheter, showing catheter entrapment within the stent frame when crossed at an acute angle (Online and ).

PCI after TAVR is increasing as indications for TAVR expand. Technical difficulties of coronary intervention with supracoronary valves have been described. With ex vivo simulation of our case, we concluded that catheter entrapment within the stent frame is more likely if: (1) the guide catheter crosses the stent frame at an acute angle ( Fig. 4.28 E–F, Online ), (2) a preshaped double-curved catheter is used (e.g., EBU), and (3) crossing of the stent frame through a diamond lower than the ostium occurs. We recommend the following for CA/PCI with supracoronary prostheses: (1) crossing the stent frame perpendicularly through a diamond at the same level of the coronary ostium (Online ), (2) using catheters with favorable geometry (e.g., left Judkins for left and right Amplatz [Boston Scientific, Marlborough, Massachusetts] for right CA/PCI), and (3) using a balloon and/or a guidewire to back the catheter out of the coronary ostium.


  • 1. Blumenstein J, Kim W, Liebetrau C, et. al.: Challenges of coronary angiography and intervention in patients previously treated by TAVI.Clin Res Cardiol 2015; 104: pp. 632-639.

Stroke With Valve Tissue Embolization During Transcatheter Aortic Valve Replacement Treated With Endovascular Intervention

Amornpol Anuwatworn, MD
Amol Raizada, MD
Shawn Kelly, MD
Tomasz Stys, MD
Orvar Jonsson, MD
Adam Stys, MD

A 78-year-old man presented with progressive dyspnea on exertion and syncope. His relevant history included coronary bypass surgery twice. Severe aortic stenosis with left ventricular ejection fraction of 65% was evident on echocardiography. Coronary angiogram showed patent left internal mammary artery and saphenous vein grafts with severe three-vessel disease. Transesophageal echocardiogram revealed heavily calcified, poorly opening aortic valve leaflets, and a mobile echodense mass measuring 1 cm × 0.4 cm attached to the valve ( Fig. 4.29 , Online and ). Transfemoral transcatheter aortic valve replacement (TAVR) was performed with a CoreValve system (Medtronic, Minneapolis, Minnesota) because the patient was deemed high risk for open-heart surgery. After the procedure, most of the mobile aortic valve mass was no longer seen on the transesophageal echocardiogram. When the patient awakened from sedation, right hemiplegia was noted (one-fifth strength). Head computed tomographic angiography showed narrowing involving the distal M1 segment of the left middle cerebral artery (MCA) with diminished enhancement suggestive of early infarction. Emergent cerebral angiography showed a partially occlusive defect in the M1 segment of the left MCA that was limiting the distal flow ( Fig. 4.30 ). Endovascular mechanical extraction of the mass responsible for these findings was performed with a Penumbra ACE catheter (Penumbra, Inc., Alameda, California), achieving complete recanalization ( Figs. 4.31 and 4.32 ). Subsequently, the patient’s strength improved significantly (four-fifths strength). Brain magnetic resonance imaging revealed a large acute infarct of the left MCA territory ( Fig. 4.33 ). Histopathology of the extracted mass was consistent with heart valve tissue ( Fig. 4.34 ).

FIG. 4.29

Mobile Echodense Mass Attached to Aortic Valve.

Transesophageal echocardiography shows mobile echodense mass ( white arrow ), which measured 1 cm × 0.4 cm, attached to the aortic valve (Online and ).

FIG. 4.30

Filling Defect in the Distal M1 Segment of the Left Middle Cerebral Artery.

Cerebral angiogram shows filling defect in the distal M1 segment of the left middle cerebral artery ( white arrow ) with minimal contrast distally.

FIG. 4.31

Good Flow After Retrieval of Embolic Material.

Cerebral angiogram after retrieval of embolic material from left middle cerebral artery ( white arrow ) shows good subsequent flow.

FIG. 4. 32

Gross Specimen of the Embolic Valvular Tissue.

Gross specimen of the embolic valvular tissue retrieved from the left middle cerebral artery.

FIG. 4.33

Brain Magnetic Resonance Imaging (MRI) Reveals Middle Cerebral Artery (MCA) Acute Infarct.

Brain MRI reveals a large MCA acute infarct ( white arrow ).

FIG. 4.34

Connective Tissue Core of a Heart Valve With Endothelial Lining.

Histopathology demonstrates the typical dense connective tissue core of a heart valve with endothelial lining. There is evidence of mild myxoid change and fibrous proliferative activity within the tissue.

Stroke is a well-known complication of TAVR. The incidence rate of major strokes at 30 days in the PARTNER (Placement of Aortic Transcatheter Valves) A trial was 3.8%. Svensson et al. found that 51% of strokes occurred during the procedure, and 38% of strokes occurred within 2 days; however, the mortality rate in patients with stroke was 43%. Of patients undergoing TAVR, 0.56% developed valve embolization. One case report of a TAVR patient demonstrated the successful endovascular retrieval of an embolized calcium fragment that may have derived from the aortic wall or the valve. In our case, the valve tissue recovery from the MCA resulted in significant neurologic improvement. To our knowledge, this case demonstrates the first successful endovascular recanalization of acute ischemic stroke caused specifically by valve tissue embolization. Endovascular intervention should be considered as emergency rescue therapy for acute ischemic stroke resulting from valve tissue emboli.

▪ Acknowledgments

The authors thank Dr. Jitendra Sharma for providing advanced interventional neurology care and postprocedure photographs of retrieved valvular tissue. Special thanks to Dr. David W. Ohrt and Dr. Usama Yusef for providing the histopathology slide.


  • 1. Svensson LG, Tuzcu M, Kapadia S, et. al.: A comprehensive review of the PARTNER trial.J Thorac Cardiovasc Surg 2013; 145: pp. S11-S16.

  • 2. Jilaihawi H, Chakravarty T, Weiss RE, Fontana GP, Forrester J, Makkar RR: Meta-analysis of complications in aortic valve replacement: comparison of Medtronic-CoreValve, Edwards-Sapien and surgical aortic valve replacement in 8,536 patients.Catheter Cardiovasc Interv 2012; 80: pp. 128-138.

  • 3. Fassa AA, Mazighi M, Himbert D, et. al.: Successful endovascular stroke rescue with retrieval of an embolized calcium fragment after trans- catheter aortic valve replacement.Circ Cardiovasc Interv 2014; 7: pp. 125-126.

Successful Management of Annulus Rupture in Transcatheter Aortic Valve Implantation

Kentaro Hayashida, MD, PhD
Erik Bouvier, MD
Thierry Lefèvre, MD

An 82-year-old woman with severe aortic stenosis was referred to our center. Transcatheter aortic valve implantation (TAVI) was scheduled because of her high surgical risk (logistic EuroSCORE [European System for Cardiac Operative Risk Evaluation] 25.8%). The annulus diameter measured by transesophageal echocardiography (TEE) was 22.2 and 23.6 mm by multidetector computed tomography (CT). A 26-mm Edwards valve (Edwards Lifesciences, Irvine, California) was subsequently implanted via the transfemoral approach. After implantation, sudden hemodynamic collapse occurred, and aortography revealed contrast protrusion from the aortic cusp ( Fig. 4.35 A, Online ). Fluoroscopic detection of restricted heart motion with surrounding white area (Online ) facilitated immediate diagnosis of tamponade before echocardiography. After percutaneous pericardial drainage via the subxiphoid approach and heparin neutralization, blood autotransfusion was performed via a circuit connecting the drainage catheter and the femoral vein sheath. Hemodynamics were stabilized within 30 min, and contrast protrusion disappeared (Online ). Preprocedural CT showed a calcified nodule (5 × 7.5 mm) at the epicardial fat segment between the interventricular septum and left atrium ( Fig. 4.35 B, arrow ), and contrast leakage was observed in postprocedural CT ( Fig. 4.35 C, arrow ). The patient was discharged on day 8 with no complications. We successfully treated a similar case (with a 26-mm valve for the 22-mm TEE-measured annulus diameter) with contrast protrusion ( Fig. 4.35 D, Online and ) and similar pre- and post-CT findings ( Fig. 4.35 E–F). Annulus rupture is a rare complication of TAVI, reported in about 1% of cases. , However, when it occurs, acute hemodynamic collapse frequently causes catastrophic outcomes. Immediate diagnosis by fluoroscopy and echocardiography, percutaneous drainage, autotransfusion of drained blood, and heparin neutralization may save lives.

FIG. 4.35

Angiographic and Computed Tomography (CT) Images of Annulus Rupture in Patient No.

1 and Patient No. 2. (A) Aortography showed contrast protrusion from the aortic cusp (anteroposterior view) (Online ). (B) Preprocedural CT scan showed a huge calcified nodule (5 × 7.5 mm) on the annulus ( arrow ). (C) Postprocedural CT scan showed contrast leakage due to annulus rupture ( arrow ). (D) Contrast protrusion from the aortic cusp in another case of annulus rupture (left anterior oblique 20°) (Online ). (E) A calcified nodule on the annulus on preprocedural CT scan ( arrow ). (F) Postprocedural CT scan (Online ).


  • 1. Pasic M, Unbehaun A, Dreysse S, et. al.: Rupture of the device landing zone during transcatheter aortic valve implantation: a life-threatening but treatable complication.Circ Cardiovasc Interv 2012; 5: pp. 424-432.

  • 2. Hayashida K, Bouvier E, Lefevre T, et. al.: Potential mechanism for annulus rupture in transcatheter aortic valve implantation.Catheter Cardiovasc Interv 2013; 82: pp. E742-E746. doi:10.1002/ccd.24524. [Epub 2013 Jun 25.]

Valve Migration Into the Left Ventricular Outflow Tract Managed by Coaxial Double-Valve Alignment

Annamaria Nicolino, MD
Massimo Vischi, MD
Shahram Moshiri, MD
Antonio Salsano, MD
Giancarlo Passerone, MD
Francesco Chiarella, MD
Francesco Santini, MD

The efficacy and overall safety of transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis at high risk for conventional surgery is validated. Nevertheless, infrequent but severe intraprocedural complications, often necessitating intraoperative bail-out maneuvers, are reported. Among these, valve migration into the left ventricle is particularly dismal and requires conversion to an emergent surgical procedure with a reported disproportionally high mortality rate.

We report herein a case in which valve migration into the left ventricular outflow tract (LVOT) was successfully managed by repositioning a second prosthesis, thus avoiding emergent surgery.

An 81-year-old woman with severe symptomatic aortic stenosis and a logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) of 26% was admitted for transfemoral TAVI. At computed tomography (CT) scan, aortic valve and root measurements showed an annulus diameter of 21 ×23 mm (mean 22 mm), a perimeter of 7.1 cm, an area of 3.7 cm 2 ( Fig. 4.36 A–B), an aortic root at the level of the sinus of Valsalva of 26 × 28 mm, and a sinotubular junction of 23 × 25 mm.

FIG. 4.36

Computed Tomography Scan of the Aortic Valve and Root Measurements.

Aortic valve (A) and annular (B) measures. (C) Aortic valve calcifications involving mainly two leaflets and scarcely the annulus.

Interestingly, calcifications were present only on two valve leaflets and very scarcely on the annulus ( Fig. 4.36 C). Because of the borderline annular size, a calibrated balloon aortic valvuloplasty was performed, with the evidence that a 20-mm size completely occluded the annulus. A 23-mm Edwards SAPIEN XT valve (Edwards Lifesciences, Irvine, California) was therefore deployed as for a routine procedure during rapid pacing at the proper annular position ( Fig. 4.37 , Online ).

FIG. 4.37

First Valve After Deployment at the Annular Level.

Fluoroscopic view showing the first 23-mm Edwards SAPIEN XT valve deployed in the correct position (Online ).

Immediately after valve implantation, however, a self-limiting ventricular tachycardia occurred, and fluoroscopy showed the valve had migrated into the LVOT ( Fig. 4.38 , Online ). In view of the rapidly deteriorating hemodynamics with marked hypotension (90/60 mm Hg) and bradycardia requiring inotropic support, tracheal intubation, and ventricular pacing, having excluded by transesophageal echocardiography (TEE) any involvement of the mitral valve, the heart team decided on an emergency, lifesaving, second aortic valve deployment with the concurrent intent of repositioning the previous prosthesis. The decision was made in view of the patient’s prohibitive overall clinical conditions for surgery, including a very high frailty score (Geriatric Status Scale).

FIG. 4.38

Migrated Valve at the Subannular Level.

Fluoroscopic view showing the 23-mm Edwards SAPIEN XT valve migrated into the left ventricular outflow tract (Online ).

Again, a second 23-mm Edwards SAPIEN XT valve was deployed, slightly overinflated by means of a balloon prepared with 2 mL of extradilute contrast medium, and in a higher position than the previous valve in the aortic annulus ( Fig. 4.39 A–B, Online ). Furthermore, after balloon deflection and without rapid pacing, by using the delivery system tip of the second valve balloon catheter, the lower-edge mesh frame of the first inserted valve was engaged and carefully pulled back to a stable position in the LVOT, coaxial to the second deployed prosthesis ( Fig. 4.40 , Online ). The patient regained hemodynamic stability, allowing rapid withdrawal of inotropic support. TEE excluded any mitral regurgitation or restriction of the anterior mitral leaflet motion. The patient was discharged on day 7 after permanent pacemaker implantation for persistent complete atrioventricular block.

FIG. 4.39

Deployment of the Second Valve.

Fluoroscopic view showing the second 23-mm Edwards SAPIEN XT valve in position before (A) and after (B) balloon dilation (Online ).

FIG. 4.40

Coaxial Position of the Two Valves.

Fluoroscopic view showing the coaxial double-valve left ventricular outflow tract alignment achieved after balloon catheter retrieval (Online ).

At 12 months of follow-up, the patient is stable in New York Heart Association functional class I and has had no adverse events in the interim period. The electrocardiogram shows sinus rhythm and normal atrioventricular conduction, with no pacemaker intervention. Serial echocardiograms, radiographic controls, and CT angiography ( Fig. 4.41 , Online ) showed stable valve positions and no mitral dysfunction.

FIG. 4.41

Cine Computed Tomographic (CT) Scan at Follow-Up.

Contrast material–enhanced electrocardiographically gated CT angiography showing the stable coaxial alignment of the two deployed valves at 9 months follow-up (Online ).

Transcatheter heart valve migration is a largely, but not entirely, preventable complication with current balloon-expandable valves. An asymmetrically calcified aortic valve and a borderline annular size may have favored prosthesis migration by preventing proper annular anchoring. A 23-mm prosthesis was chosen to minimize complications of a smallish aortic root and after calibrated measurements. It is conceivable that a more aggressive valve dilation in the first instance might have prevented valve migration. During the procedure, the position of the pigtail was higher than recommended but still deemed satisfactory to visualize the annulus during aortography. We chose to inflate the valve according to the “two-step implantation technique” to be able to adjust the position should it have become necessary. Retrospectively, the potential impact of the two-step technique on valve migration cannot be excluded. Nevertheless, the evidence that the valve prosthesis stayed in position for a given time seems to underscore that the applied radial forces rather than the application time might have had more of an impact on the final result.

Although prevention with meticulous image analysis and sizing remains the key to success, the prompt availability of an interdisciplinary surgical and interventional safety net to manage bail-out maneuvers in potentially fatal complications is confirmed to be mandatory. In our case, excluded any mitral valve involvement, the decision to proceed with a second deployment was made in view of the patient’s prohibitive clinical conditions, further worsened by the casualty, and by the reported evidence of poor surgical results in an emergency setting. ,

Although our approach was successful, the potential for a disastrous outcome and therefore the need for extensive planning should never be underestimated.


  • 1. Hein R, Abdel-Wahab M, Sievert H, et. al.: Outcome of patients after emergency conversion from transcatheter aortic valve implantation to surgery.EuroIntervention 2013; 9: pp. 446-451.

  • 2. Makkar RR, Jilaihawi H, Chakravarty T, et. al.: Determinants and outcomes of acute transcatheter valve-in-valve therapy or embolization: a study of multiple valve implants in the U.S. PARTNER trial (Placement of AoRTic TraNscathetER Valve Trial Edwards SAPIEN Transcatheter Heart Valve).J Am Coll Cardiol 2013; 62: pp. 418-430.

Vascular Injury Caused by Retrieval of Ruptured and Detached Balloon Valvuloplasty Catheter During Transcatheter Aortic Valve Replacement

Shunsuke Kubo, MD
Yasushi Fuku, MD
Takeshi Shimamoto, MD, PhD
Akimune Kuwayama, MD
Masanobu Ohya, MD
Hidewo Amano, MD
Takeshi Maruo, MD
Tsuyoshi Goto, MD
Tatsuhiko Komiya, MD, PhD
Kazushige Kadota, MD, PhD

An 88-year-old woman underwent transcatheter aortic valve implantation using a SAPIEN 3 valve (Edwards Lifesciences, Irvine, California) for symptomatic severe aortic stenosis. Preprocedural examinations showed an aortic valve area of 0.39 cm 2 and severe calcification of the leaflets. During predilatation using a 20-mm balloon valvuloplasty catheter (Edwards Lifesciences), balloon rupture occurred at the calcified leaflet ( Fig. 4.42 ). We pulled the balloon catheter back to the eSheath (Edwards Lifesciences) and removed it together with the eSheath through the right femoral artery. The ruptured balloon was, however, completely detached and a part of the balloon remained in the artery ( Fig. 4.43 A). Iliac angiography showed the right external iliac artery occluded with the detached balloon ( Fig. 4.43 B–C). After heart team discussion, we cut down the groin and successfully retrieved the detached ruptured balloon ( Fig. 4.43 D–E). Then, a 23-mm SAPIEN 3 valve was implanted via left femoral access. After percutaneous closure of the left femoral access site, the right limb appeared to have developed cyanosis. Right limb angiography revealed that the superficial femoral artery was occluded due to embolization ( Fig. 4.44 A). After removal of the embolized material through the cutdown site, the right superficial femoral artery was recanalized ( Fig. 4.44 B) and the cyanosis improved. The retrieved material was pathologically proved to be an arterial intima ( Fig. 4.44 C). This finding indicates that a ruptured balloon caused vascular injury in the process of retrieval, and the dissected free arterial intima embolized the right femoral artery.

FIG. 4.42

Fluoroscopic and Echocardiographic Findings of Balloon.

FIG. 4.43

Retrieved Ruptured Balloon Valvuloplasty Catheter.

(A) The initially retrieved balloon catheter showing an extended shaft and a part of the balloon. Iliac angiography showing the occlusion of the external iliac artery (B) with a detached ruptured balloon ( white circle ) (C). (D) Retrieval of the detached balloon by cutting down the groin. (E) Successful retrieval of two parts of the ruptured balloon ( yellow circle ).

FIG. 4.44

Superficial Femoral Artery (SFA) Occlusion Due to Arterial Intimal Embolization.

(A) Right femoral angiography showing SFA occlusion due to embolization. (B) After removal of the embolized material, the SFA was successfully recanalized. (C) Removed embolized material indicating an arterial intima.

Balloon rupture can occur during valvuloplasty of a severely calcified aortic valve. In this case, we tried to pull out the ruptured balloon catheter, which resulted in complete detachment of the balloon, arterial injury, and subsequent embolization with a resected arterial intima. Retrieval of a ruptured balloon valvuloplasty catheter is occasionally challenging, and careful management is required to prevent serious vascular complications.


  • 1. Percutaneous balloon aortic valvuloplasty: Acute and 30-day follow-up results in 674 patients from the NHLBI Balloon Valvuloplasty Registry.Circulation 1991; 84: pp. 2383-2397.

Very Late Thrombosis of a Transcatheter Aortic Valve-in-Valve

David Martí, MD, PhD
Miguel Rubio, MD
Natalia Escribano, MD
Ramón de Miguel, MD
Ignacio Rada, MD, PhD
César Morís, MD, PhD

An 85-year-old man presented with dyspnea (New York Heart Association functional class IV) 4 years after implantation of a 26-mm CoreValve transcatheter aortic valve (TAV) (Medtronic, Minneapolis, Minnesota). Angiography revealed severe aortic regurgitation because of the deep position of the prosthesis (Online ), and a 23-mm SAPIEN XT (Edwards Lifesciences, Irvine, California) valve-in-valve implantation was performed. Midterm follow-up was favorable; clopidogrel was discontinued 15 months after the SAPIEN XT valve implantation, and aspirin monotherapy continued thereafter.

Two months after clopidogrel discontinuation, the patient required three visits to the emergency department with overt heart failure. Echocardiography showed high transvalvular gradients (peak, 55 mm Hg; mean, 31 mm Hg; dimensionless valve index, 0.25), thickened leaflets, and mild to moderate central aortic regurgitation ( Fig. 4.45 , Online and ). The heart team decided to perform a surgical aortic valve replacement. Operative and pathology findings revealed a diffuse fibrin-platelet thrombus adhered to the aortic surface on the three SAPIEN XT valve cusps ( Figs. 4.46 and 4.47 ). This valve was partially denuded and easily extracted from within the CoreValve prosthesis. Both TAVs were explanted via a longitudinal aortotomy, and a 21-mm bioprosthesis was sutured to the well-preserved aortic annulus. Unfortunately, the patient died of cardiac arrest in the postoperative period.

FIG. 4.45

Multiplane Transesophageal Echocardiography.

(Left) Homogeneous thickening of the SAPIEN XT (Edwards Lifesciences, Irvine, California) cusps, with neither significant calcification nor mobile images. (Right) Elevated transvalvular velocities (Online ).

FIG. 4.46

Operative Findings Revealing Thrombotic Material Adhered to the Three Aortic Cusps.

Note the endothelialization of the CoreValve (Medtronic, Minneapolis, Minnesota) frame and the proper expansion of the SAPIEN XT valve (Edwards Lifesciences, Irvine, California).

FIG. 4.47

Pathologic Sample of a Thrombosed Leaflet.

Masson trichrome-stained section of a thrombosed leaflet, with lines of Zahn present and without fibrosis or calcification within the thrombus (magnification ×4). L , leaflet; T , thrombus.

Valve thrombosis is a rare but increasingly recognized complication of transcatheter heart valves. Indeed, a systematic review has shown that thrombosis is the major cause of valve stenosis in the early years after implantation. As in this case, TAV thrombosis is usually not associated with typical thrombus images on transesophageal echocardiography, and operators must be cautious when handling catheters in the vicinity of a stenotic TAV. ,

Balloon-expandable prostheses are sometimes used to reduce aortic regurgitation after CoreValve implantation. Our findings suggest that in this setting, internal prosthesis endothelialization may be delayed or incomplete, representing an additional risk factor for late thrombosis. Therefore TAV-in-TAV therapies with balloon-expandable valves might require longer duration of dual-antiplatelet therapy.


  • 1. Mylotte D, Andalib A, Thériault-Lauzier P, et. al.: Transcatheter heart valve failure: a systematic review.Eur Heart J 2015; 36: pp. 1306-1327.

  • 2. De Backer O, Ihlemann N, Olsen NT, Vejlstrup N, Søndergaard L: Intracardiac echocardiography unveils large thrombus on a restenotic TAVR prosthesis more than 6 years after implantation.Eur Heart J 2016; 37: pp. 2271. doi:10.1093/eurheartj/ehv064. [Epub 2015 Mar 22.]

  • 3. Diemert P, Lange P, Greif M, et. al.: Edwards Sapien XT valve placement as treatment option for aortic regurgitation after transfemoral Core Valve implantation: a multicenter experience.Clin Res Cardiol 2014; 103: pp. 183-190.

Balloon “Valvuloplasty” for Mechanical Valve Dysfunction

David E. Kandzari, MD
Harold Carlson, MD
John P. Gott, MD
Prashant Kaul, MD
W. Morris Brown, MD

A 46-year-old woman with a history of Marfan syndrome experienced witnessed cardiac arrest with persistent shock requiring circulatory support with extracorporeal membrane oxygenation (ECMO). In 2000, the patient underwent ascending aortic root replacement and mechanical bileaflet valve replacement followed by second sternotomy in 2012 with bypass grafting to the left anterior descending artery and left main artery patch closure for progressive coronary aneurysmal enlargement.

Coronary angiography demonstrated no significant right coronary artery disease but severe stenosis at the origin of the single venous bypass graft to the left coronary anatomy ( Fig. 4.48 ). During successful percutaneous revascularization of the bypass graft, a fixed, immobile leaflet of the mechanical valve was identified ( Fig. 4.49 A–B, Online ). The international normalized ratio was within therapeutic range upon admission. After surgical consultation, the risk of a third operation was considered prohibitive. Furthermore, given prolonged cardiopulmonary resuscitation and ECMO cannulation, fibrinolytic therapy for possible valve thrombosis represented at least a relative contraindication.

FIG. 4.48

Bypass Graft Angiography to Left Coronary Anatomy.

Angiography demonstrating severe stenosis of solitary venous bypass graft to left coronary arteries.

FIG. 4.49

Fluoroscopy of Immobile Prosthetic Valve Leaflet.

After successful revascularization, fluoroscopy indicates a single, fixed, immobile valve leaflet during diastole (A) and systole (B) (Online ).

With no alternative therapeutic options, we hypothesized that balloon expansion between the leaflet struts may free the fixed leaflet and restore mobility. The method was initially tested with a valve model in the catheterization laboratory. A coronary guidewire was then passed across the valve between the struts followed by advancement of a 2.5- × 20-mm angioplasty catheter ( Fig. 4.50 A, Online ). Inflation of the balloon immediately resulted in recovery of leaflet mobility ( Fig 4.50 B) with functional aortic regurgitation and no clinical or radiographic evidence of an embolic event ( Fig. 4.51 A–B, Online ).

FIG. 4.50

Balloon “Valvuloplasty” of Fixed Prosthetic Valve Leaflet.

Advancement of a coronary balloon angioplasty catheter between the valve struts (A) and recovery of leaflet mobility (B) (Online ).

FIG. 4.51

Recovery of Normal Prosthetic Valve Bileaflet Function.

Supravalvular angiography confirming leaflet mobility in diastole (A) and systole (B) (Online ).

Treatment options for prosthetic valve dysfunction are limited to surgery or fibrinolytic therapy, both of which were unfavorable in this situation. After reviewing the medical literature, we find that this case represents the first description of balloon “valvuloplasty” for mechanical valve dysfunction.

Transesophageal Echocardiography-Guided, Bedside Bail-Out Aortic Valvuloplasty

Mathias C. Busch, MD
Sigrun Friesecke, MD
Klaus Empen, MD
Stephan B. Felix, MD

A 73-year-old man developed hemodynamic deterioration in the context of bilateral pneumonia, despite treatment of septic shock according to guidelines. Transthoracic echocardiography was of poor quality because of the patient’s obesity but revealed severely reduced left ventricular (LV) function. Significant coronary heart disease had previously been ruled out angiographically. With hemodynamic status deteriorating further (intermittently requiring cardiopulmonary resuscitation), implantation of a percutaneous LV assist device (Impella, Abiomed, Danvers, Massachusetts) was planned. Because current circumstances made transfer to the catheterization laboratory impossible, transesophageal echocardiography (TEE)-guided implantation in the intensive care unit was initiated. The ultrasound image, however, revealed severe aortic valve (AV) stenosis ( Fig. 4.52 A), inaudible on auscultation. A transfemoral AL1-shaped 5F catheter was placed in the ascending aorta. The AV was passed under TEE guidance with a straight-tip hydrophilic guidewire ( Fig. 4.52 B). After advancement of the catheter into the LV, pressure measurement with the intensive care unit monitor showed a peak-to-peak gradient of approximately 50 mm Hg. A J-tipped extra-stiff guidewire was placed into the LV. A NuMed NuCLEUS (Hopkington, New York) 23-mm balloon was advanced across the AV with TEE guidance ( Fig. 4.52 C). Valvuloplasty was performed ( Fig. 4.52 D) without rapid ventricular pacing in the setting of low-output cardiac failure, immediately leading to dramatic hemodynamic improvement. After further stabilization, transcatheter aortic valve implantation (CoreValve, Medtronic, Minneapolis, Minnesota) was performed several days later. Over the following days LV function recovered to ejection fraction 45%, and hemodynamic status stabilized without the need of vasopressors.

FIG. 4.52

Transesophageal Echocardiography (TEE).

(A) Heavily calcified, highly stenosed aortic valve in cross-sectional TEE view. (B) TEE-guided wire placement. (C) TEE-guided placement of valvuloplasty balloon. (D) Balloon inflation.

The images demonstrate the pitfalls of nondiagnostic imaging in an emergency situation and how an innovative strategy can help in an unexpected difficult situation.

First Successful Management of Aortic Valve Insufficiency Associated With HeartMate II Left Ventricular Assist Device Support by Transfemoral CoreValve Implantation: Columbus’ Egg?

Francesco Santini, MD
Alberto Forni, MD
Rajesh Dandale, MD
Flavio Ribichini, MD
Andrea Rossi, MD
Gianluigi Franchi, MD
Francesco Onorati, MD
Corrado Vassanelli, MD
Alessandro Mazzucco, MD
Giuseppe Faggian, MD

Left ventricular assist device (LVAD) support has offered many individuals with end-stage heart failure an improved quality of life and enhanced survival. Prolonged mechanical assistance, however, has shown the potential to induce hemodynamic and structural changes in the native heart. One such dismal drawback is the development of de novo aortic valve lesions leading to aortic insufficiency (AI). Significant AI can lead to ineffective LVAD output and end-organ malperfusion, and may hamper the success of recovery attempts. If AI at the time of LVAD implantation can be proactively managed by replacement or closure of the aortic valve, later development of aortic valve dysfunction may pose a difficult management issue.

A 53-year-old male patient (height, 190 cm; weight, 90 kg) with end-stage dilated cardiomyopathy was uneventfully implanted with a Thoratec HeartMate II LVAD (Thoratec Corporation, Pleasanton, California) intended as a bridge to transplantation. Ten months postoperatively, he showed progressively worsening AI, requiring hospital readmissions for increased exercise intolerance, desaturation, and arrhythmia. In view of the unfavorable anthropometric characteristics, any attempt to anticipate transplantation was unsuccessful for lack of appropriate donors. Ineffective LVAD output, pulmonary edema with desaturation, and arrhythmia ultimately required endotracheal intubation and cardiopulmonary resuscitation. Because neither optimal medical therapy nor LVAD adjustments provided hemodynamic stability, the heart team decided on emergency lifesaving aortic valve implantation ( Fig. 4.53 , Online ). Transcatheter aortic valve implantation was undertaken with a percutaneous approach through the right femoral artery. Through an 18F introducer, an extra-stiff guidewire was positioned in the left ventricle, and a 29-mm CoreValve (Medtronic, Minneapolis, Minnesota) was implanted under fluoroscopy and echo control. Because of a moderate periprosthetic regurgitation ( Fig. 4.54 , Online ), a second 29-mm CoreValve was deployed within the previous valve prosthesis ( Fig. 4.55 ), with minimal residual leak ( Fig. 4.56 , Online ) and no complications. The femoral access was repaired by the Prostar XL closure device (Abbott Vascular, Santa Clara, California). The patient’s hemodynamics improved immediately and led to a successful extubation by postoperative day 1. At the time of discharge, echocardiography displayed very little residual regurgitation. The patient is currently in New York Heart Association functional class II, waiting for heart transplantation.

FIG. 4.53

Fluoroscopic View Showing Severe Aortic Valve Regurgitation Along With the HeartMate II Device.

See also Online .

Aug 4, 2020 | Posted by in CARDIOLOGY | Comments Off on Structural heart disease: Complications and techniques
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