Valve-in-Valve Implantation for Aortic Annular Rupture Complicating Transcatheter Aortic Valve Replacement (TAVR)

Abstract: An 83-year-old woman with multiple comorbidities and severe aortic stenosis presented with recurrent pulmonary edema. In light of her high surgical risk, a percutaneous strategy for her aortic stenosis was decided. Transcatheter aortic valve replacement using a balloon-expandable Edwards Sapien XT valve was performed under rapid ventricular pacing. Soon after valve deployment, the patient went into hemodynamic collapse due to annular root rupture with pericardial tamponade, necessitating urgent pericardial decompression. Using a valve-in-valve technique, with the deployment of a second Edward Sapien XT valve inside the first valve, the annular root rupture was successfully sealed leading to hemodynamic recovery.

J INVASIVE CARDIOL 2013;25(8):409-410

Key words: aortic stenosis, valve disease

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Symptomatic severe aortic stenosis (AS) is associated with significant mortality when managed conservatively.¹ While surgical aortic valve replacement (AVR) remains the gold standard of treatment for AS, a significant proportion of patients are denied this procedure.²

Transcatheter aortic valve replacement (TAVR) has emerged as a viable alternative to AVR in these patients.³ While procedural success in this relatively new procedure is high, TAVR is still associated with uncommon but potentially catastrophic complications.⁴ Aortic root rupture remains a rare but potentially lethal complication.⁵ To date, patients who have survived have been salvaged with emergent surgical bail-out. Here, we report a case of annular root rupture complicating TAVR that was sealed with a transcatheter valve-in-valve approach.

Case Report

A frail 83-year-old woman presented with recurrent pulmonary edema in the context of severe AS. Her comorbidities included previous coronary artery bypass grafting and chronic obstructive lung disease. Cardiac catheterization demonstrated a mean transaortic gradient of 40 mm Hg and an aortic valve area of 0.6 cm². Coronary angiography showed patent saphenous vein grafts to the left anterior descending and obtuse marginal circumflex arteries. Given her comorbidities (logistic Euroscore, 32%) and frailty, the patient was deemed high risk for AVR and was offered TAVR.

TAVR was performed using a balloon-expandable transcatheter heart valve (Sapien XT, Edwards Lifesciences) via the right femoral artery. Based on an aortic annulus diameter measurement of 23 mm by transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE), a 26 mm Sapien XT valve was chosen in accordance with current sizing recommendations. After balloon aortic valvuloplasty with a 23-mm diameter balloon, the transcatheter heart valve was deployed under rapid ventricular pacing at 200 beats/minute. Aortography post TAVR showed a well-positioned transcatheter aortic valve with a faint eccentric streak of contrast under the left coronary cusp that was initially thought to be paravalvular incompetence (Figure 1A). Unexpectedly, the patient developed rapid hemodynamic collapse and shock several minutes after successful percutaneous closure of the right femoral artery access site. Peripheral vascular angiography excluded vessel perforation. Repeat TEE revealed an evolving pericardial effusion with left atrial collapse and cardiac tamponade. Emergent surgical drainage of the posteriorly located effusion was performed on the cardiac catheterization laboratory table by left-sided thoracotomy. Hemodynamic support with extracorporeal membrane oxygenation (ECMO) along with aggressive blood transfusion was rapidly instituted.

Following surgical decompression of the pericardial space, repeat aortography (Figure 1B) clearly demonstrated aortic annular rupture, with contrast seen extending from the ventricular margin of the prosthesis at the left coronary cusp into the pericardial space. On TEE, this corresponded to abnormally high-velocity color flow at the aortic annular level (Figure 1C). Based on the aortogram, we hypothesized that contrast was likely tracking around the aortic margin of the aortic valve prosthesis skirt to the site of annular rupture into the pericardial space. In an effort to seal the passage of blood around the aortic margin of the transcatheter valve skirt, we elected to deploy a second 26 mm Sapien XT valve within the first prosthesis, approximately one stent strut above the original (Figure 2A). 

Postdeployment aortography (Figure 2B) demonstrated resolution of the contrast leak into the pericardial space, a finding that was confirmed on TEE with disappearance of the previously noted abnormal color flow (Figure 2C). 

After valve-in-valve implantation, the patient’s hemodynamics rapidly stabilized. She was weaned off ECMO, transferred to the intensive care unit, and extubated within 24 hours. On day 3, the patient developed acute abdominal pain associated with progressive hemodynamic compromise and a rapidly rising serum lactate. The patient’s hemoglobin remained stable and repeat echocardiography demonstrated a satisfactorily functioning aortic bioprosthesis without evidence of pericardial effusion. A presumptive diagnosis of ischemic bowel as a result of prolonged hemodynamic compromise during the TAVR procedure was made. The patient succumbed a few hours after symptom onset from shock.

Discussion

Aortic annular rupture is an uncommon but catastrophic complication of TAVR, for which there are currently no percutaneous bail-out options. Our case illustrates the initially subtle presentation and rapidly progressive nature of this TAVR complication. Risk factors for annular rupture include heavy annular calcification, aggressive balloon valvuloplasty, and excessive oversizing of the transcatheter heart valve.⁶ Manifestations of annular rupture depend on the specific site of injury. They include pericardial tamponade, membranous ventricular septal defect, and/or perforation of the anterior mitral valve curtain.⁴ Clear visualization of annular rupture can be facilitated by depressurizing the pericardial space and assist in developing therapeutic strategies. Salvage surgery for annular rupture carries a considerable mortality risk. While our patient succumbed from ischemic bowel complicating prolonged hemodynamic compromise, our experience suggests that transcatheter valve-in-valve deployment may be effective in sealing certain types of aortic annular rupture.

References

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