Severe Functional Mitral Regurgitation and Cardiogenic Shock After Transcatheter Aortic Valve Replacement
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An 83-year-old woman with symptomatic severe aortic stenosis (AS) was referred for transcatheter aortic valve replacement (TAVR). Diagnostic left heart catheterization (LHC) documented diffuse 3-vessel coronary artery disease (CAD) (Videos 1-3). Transthoracic echocardiogram (TTE) showed normal biventricular function, severe AS, and minimal mitral regurgitation (MR) (Figure 1A and B; Video 4). The Heart Team deemed that she was at high/prohibitive surgical risk given multiple comorbidities and frailty.
The patient underwent transfemoral TAVR with a 25-mm Navitor valve (Abbott) after initial ballon aortic valvuloplasty (BAV). TTE and angiography documented normal valve positioning and function, and normal coronary perfusion. Within a few minutes of the deployment of the valve, the patient developed persistent hypotension and vasopressors were initiated. TTE showed anteroseptal hypokinesis and severe MR with a centrally directed jet (Figure 1C and D; Video 5). The patient was intubated, and transesophageal echocardiogram (TEE) confirmed severe MR with a broad, centrally directed jet from poor mitral leaflet coaptation (Figure 2A and B; Videos 6 and 7). A diagnostic left heart cardiac catheterization showed no changes in the underlying CAD. An intra-aortic balloon pump was placed, and TEE showed MR improvement from severe to mild (Figure 2C; Video 8). The patient was moved to the cardiac intensive care unit for continuous hemodynamic monitoring. Her clinical course progressively improved and she was discharged home on post-procedure day 7 in stable condition.
Severe functional MR with ensuing cardiogenic shock is a rare complication after TAVR. In this case, it was likely due to transient left ventricular dysfunction because of hypoperfusion from rapid pacing during BAV and TAVR deployment. Intra-procedural echocardiography is crucial for rapid detection and differential diagnosis of cardiogenic shock after the TAVR procedure and can be lifesaving, as demonstrated by our case.
![Figure 1. Transthoracic echocardiogram](https://d148x66490prkv.cloudfront.net/hmp_ln/inline-images/Figure%201_205.png)
![Figure 2. Transesophageal echocardiogram](https://d148x66490prkv.cloudfront.net/hmp_ln/inline-images/Figure%202_147.png)
Affiliations and Disclosures
From the 1Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA; 2UCD School of Medicine, University College Dublin, Belfield, Dublin, Ireland; 3RUHS College of Medical Sciences, Jaipur, India; 4Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Dr. Akinmolayemi and Charlotte McCreery contributed equally to the manuscript.
Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.
Consent statement: The authors confirm that the patient has given informed consent for this publication.
Address for correspondence: George D. Dangas, MD, PhD, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA. Email: george.dangas@mountsinai.org; X: @DAkinmolayemi, @prandi_fr