Rheumatic Bicuspid Aortic Valve Causing Device Embolization during Transcatheter Aortic Valve Replacement| Stephy Publishers

 


SOJ Cardiology and Current Trends in Surgery - (SOJCCTS)| Stephy Publishers 

Abstract
Transcatheter aortic valve replacement (TAVR) has emerged as a feasible alternative for treatment of severe aortic stenosis with comparable outcomes to surgical aortic valve replacement (SAVR) in recent years. We present a case of device embolization in the left ventricular outflow tract (LVOT) during TAVR in a patient with severe aortic stenosis that required emergent surgical intervention. During the open-heart surgery for embolized prosthesis extraction and SAVR, both TEE exam and surgical specimen demonstrated bicuspid aortic valve and rheumatic nature of the valve with lack of calcification, which were identified to be the two main factors that contributed to the complication. In which the insufficient annular calcification increases the risk of device embolization due to lack of an adequate landing zone for device anchoring, and the anatomy of bicuspid valve contributes to the complication due to its associated large annular size and horizontal aorta. This case highlights device embolization as one possible complication of TAVR which is associated with substantial morbidity and mortality, the clinical management process was thoroughly documented with aortic angiography and transoesophageal echocardiography imaging.

 

Glossary
Transcatheter aortic valve replacement, Device embolization, Rheumatic valve, Bicuspid aortic valve

 

Introduction
The role of transcatheter aortic valve replacement (TAVR) in the treatment of patients with severe aortic stenosis (AS) has evolved since its first FDA approval in 2012. The landmark series of Placement of Aortic Transcatheter Valve (PARTNER) trials reflected robust evidence for TAVR in high, intermediate, and low risk patients. Moreover, technologic improvements and procedure simplification have contributed to increased volume of TAVRs. Complications of TAVR include access site or aortic vascular injury such as dissection, stenosis, perforation, rupture, and aneurysm. Other procedure related complications are associated with device landing zone which include aortic annular rupture, left ventricular perforation, cardiac tamponade, and device embolization. Conduction disturbances, stroke, paravalvular leak, and coronary obstruction can also occur after TAVR. Around 1% of patients undergoing TAVR require surgical bailout with the most common reasons being valve dislodgement (22%), ventricular rupture (19.9%) and rupture of the aortic valve (14.2%).1 Valve embolization is an infrequent event with an incidence of 0.2% to 1.7% and accounts for about 45% of emergency cardiac surgery in patients treated with TAVR.1 We present the case of a patient undergoing TAVR complicated by device embolization in the left ventricular outflow tract (LVOT) requiring emergent surgical intervention.

 

Case Presentation

A 50-year-old male with a past medical history of essential hypertension, paroxysmal atrial fibrillation, and cerebral vascular disease presented to our institution with palpitations, substernal chest pain and worsening shortness of breath. He was diagnosed with severe AS and evaluated by cardiothoracic surgery for surgical aortic valve replacement (SAVR). His predicted operative morbidity or mortality of surgical aortic valve replacement based on the Society for Thoracic Surgeons database (STS score) was calculated to be 1.4% (low risk), however, he rejected surgical intervention thus TAVR was planned. A comprehensive workup was performed including transthoracic echocardiography (TTE) which revealed a left ventricular ejection fraction (LVEF) of 35%, mildly dilated ascending aorta, and severe aortic valve stenosis with the following measurements: LVOT 2.0cm, annulus 2.5cm, V1 of 0.8, V2 of 3.9m/s, MG 40mmHg, AVA 0.8cm2, and no aortic regurgitation (AR). However, the aortic valve morphology was unclear and appeared to be congenital bicuspid or unicuspid on TTE. Computed tomographic (CT) evaluation of the heart revealed a tricuspid aortic valve with a hypo plastic right cusp and severe aortic valve calcification. Coronary angiogram revealed normal coronary arteries. All studies were reviewed by the multidisciplinary heart team and the decision was made to proceed with transfemoral TAVR.


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