A difficult case of retrieval of an aortic valve and balloon during a transcatheter aortic valve implantation

Unusual Case of Acute Type A Aortic Dissection During TAVR Bailout With a Self-Expanding Valve

BACKGROUND

Over the past 2 decades, transcatheter aortic valve replacement (TAVR) has emerged as a widely accepted treatment for patients with severe aortic valve stenosis. Acute aortic dissection, although rare, is a life-threatening complication associated with TAVR.

CASE SUMMARY

An older man with severe aortic stenosis underwent TAVR. During valve deployment, catheter manipulation caused intimal disruption, leading to acute type A aortic dissection (TAAD). Remarkably, the dissection spontaneously sealed after prosthetic valve placement, thereby avoiding emergency surgery. A 6-month follow-up computed tomography angiography scan showed no extension of the dissection.

DISCUSSION

In the case we report, the dissection spontaneously sealed with the use of a prosthetic valve, a finding that reinforces the feasibility of nonsurgical management of iatrogenic TAAD during TAVR in select cases.

TAKE-HOME MESSAGE

The use of a biological valve offers a novel perspective on the conservative management of iatrogenic aortic dissection in high-risk patients during TAVR.

Acute Aortic Dissection After Transcatheter Aortic Valve Replacement

Acute aortic dissection (AAD) is a rare and potentially fatal complication associated with transcatheter aortic valve replacement (TAVR). Owing to the paucity of existing institutional data, we sought to assess the incidence of postimplant AAD in patients who underwent TAVR at a single institution. All patients who underwent TAVR from 2013 to 2022 were retrospectively reviewed to identify those who possessed clinical or radiologic evidence of AAD after TAVR. Follow-up and survival data were retrieved for all included patients. A total of 4,317 patients underwent TAVR, of whom 9 (0.2%) sustained an AAD. These patients had a mean age of 80 years (range 53 to 92), mean Society of Thoracic Surgeons 30-day mortality risk of 5.7% (2.4% to 16.7%), and mean effective aortic valve area of 0.8 cm2 (0.4 to 1.5 cm2). Preoperative maximum aortic diameter was 3.9 cm (2.6 to 4 cm). Of these 9 patients, 6 (67%) showed evidence of Stanford type A dissection, whereas 3 (33%) were diagnosed with Stanford type B dissection. The most common causes of dissection were posterior annular rupture by the transcatheter valve (THV) (44%) and THV embolization or "pop-out" into the ascending aorta (22%). A total of 6 patients (66.7%), comprising 5 type A (55.6%) and 1 type B (11.1%) aortic dissections, died within 30 days of AAD. The median time to follow-up in those surviving TAVR with intraoperative AAD was 1,042 days (range: 648 to 2,666). Surviving patients were managed through thoracic endovascular aortic repair and medical management. In conclusion, in this highly selected cohort of patients, our experience indicates that AAD after TAVR is a rare but often lethal intraprocedural sequela of THV implantation, especially in cases of type A aortic dissection.

Anesthetic management of Stanford type B acute aortic dissection that occurred during transcatheter aortic valve implantation under monitored anesthesia care: A case report

We report a case involving anesthetic management of Stanford type B acute aortic dissection occurred during transcatheter aortic valve implantation (TAVI) under monitored anesthesia care (MAC) in a patient with aortic stenosis (AS). An 87-year-old woman was undergoing TAVI under MAC for severe AS. During the surgery, the patient suddenly moved possibly because of pain. This was followed by hemodynamic collapse. She was then transitioned to general anesthesia, and extracorporeal membrane oxygenation (ECMO) was initiated. Transesophageal echocardiography revealed a Stanford type B acute aortic dissection, which was safely managed perioperatively with appropriate interventions.

Immediate aortic dissection after transcatheter aortic valve replacement: A case report and review of the literature

-Aortic dissection of descending aorta was detected by intraoperative TEE in a case of 67-year-old man with symptomatic severe aortic stenosis after TAVR. -Transesophageal echocardiogram after TAVR procedure is helpful to detect this rare complication.

CoreValve Double Jeopardy: Embolized Valve Capture With Subsequent Valve

During transcatheter aortic valve replacement with a self-expanding prosthesis, prosthesis embolization represents a rare but severe complication. Etiologies of prosthesis embolization include improper sizing and malpositioning, specifically high deployment with respect to the aortic annulus. Treatment of embolization into the aorta relies upon repositioning of the prosthesis using endovascular snares or removal with open surgery. Patients with prosthesis embolization have a high risk of mortality and morbidity including stroke and aortic dissection associated with manipulation of the prosthesis in the ascending aorta. We describe a case of self-expanding prosthesis embolization and present a solution using a second prosthesis to capture the embolized one.

Effect of Balloon-Expandable Transcatheter Aortic Valve Replacement Positioning: A Patient-Specific Numerical Model

Transcatheter aortic valve replacement (TAVR) has emerged as a life-saving and effective alternative to surgical valve replacement in high-risk, elderly patients with severe calcific aortic stenosis. Despite its early promise, certain limitations and adverse events, such as suboptimal placement and valve migration, have been reported. In the present study, it was aimed to evaluate the effect of various TAVR deployment locations on the procedural outcome by assessing the risk for valve migration. The deployment of a balloon-expandable Edwards SAPIEN valve was simulated via finite element analysis in a patient-specific calcified aortic root, which was reconstructed from CT scans of a retrospective case of valve migration. The deployment location was parametrized in three configurations and the anchorage was quantitatively assessed based on the contact between the stent and the native valve during the deployment and recoil phases. The proximal deployment led to lower contact area between the native leaflets and the stent which poses higher risk for valve migration. The distal and midway positions resulted in comparable outcomes, with the former providing a slightly better anchorage. The approach presented might be used as a predictive tool for procedural planning in order to prevent prosthesis migration and achieve better clinical outcomes.

Simulation of Transcatheter Aortic Valve Replacement in patient-specific aortic roots: Effect of crimping and positioning on device performance

Calcific aortic valve disease (CAVD) is a cardiovascular condition that causes the progressive narrowing of the aortic valve (AV) opening, due to the growth of bone-like deposits all over the aortic root (AR). Transcatheter aortic valve replacement (TAVR), a minimally invasive procedure, has recently become the only lifesaving solution for patients that cannot tolerate the standard surgical valve replacement. However, adverse effects, such as AR injury or paravalvular leakage (PVL), may occur as a consequence of a sub-optimal procedure, due to the presence of calcifications in situ. Additionally, the crimping required for delivering the valve via stenting may damage the valve. The aim of the present study is to comparatively assess the crimping mechanics of the commercialized Edwards SAPIEN valve and an alternative polymeric valve (Polynova, Inc) and to evaluate the effect of different TAVR deployment positions using patient-specific numerical models. The optimal deployment location for achieving better patient outcomes was calculated and based on the interactions between the TAVR stent and the native AR. Results demonstrated that the Polynova valve withstands the crimping process better than the SAPIEN valve. Furthermore, deployment simulations showed the role that calcifications deposits may play in the TAVR sub-optimal valve anchoring to the AV wall, leading to the presence of gaps that result in PVL.

TEVAR Rescue of an Embolized Edwards SAPIEN XT Valve Following TAVR

Purpose: To report a successful method of managing an embolized Edwards SAPIEN XT aortic valve prosthesis using a thoracic endovascular aortic repair rescue. Case Report: An 84-year-old man underwent transcatheter aortic valve replacement using a 26-mm Edwards SAPIEN XT valve, which immediately embolized into the ascending aorta. Because of the severe tapering of the patient’s transverse aortic arch, the embolized valve was unable to be maneuvered further down the aorta. Therefore, a Cook 36×80-mm Zenith Dissection Endovascular System (ZDES) bare metal stent was used on a compassionate basis to append the embolized valve between the patient’s coronary artery ostia and the innominate artery takeoff within the ascending aorta, with no neurological or cardiovascular complications at 12-month follow-up. Conclusion: A Cook ZDES bare metal stent may be successfully used to append an embolized Edwards SAPIEN XT valve within the ascending aorta.

Review of reported causes of device embolization following trans-catheter aortic valve implantation

Transcatheter heart valve (THV) embolization is a rare but serious complication of transcatheter aortic valve implantation. Studies, including case reports, case series, and original reports published between 2002 and 2013, with regard to THV embolization were identified with a systemic electronic search using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. A total of 19 publications describing 71 patients were identified. Most patients (64%) were men, with a mean age of 80 ± 6 years and a mean logistic European System for Cardiac Operative Risk Evaluation score of 22.4 ± 9.3%. Balloon-expandable valves were used in 72% of the patients. The reported transcatheter aortic valve replacement access site was transfemoral in 80% of patients. Most cases (90%) occurred <1 hour after implantation, whereas 10% had late embolization (range 4 hours to 43 days). The most common site of embolization was the ascending aorta (38%), followed by the left ventricle (31%), descending aorta (23%), and aortic arch (8%). Open-heart surgery was required in 28% for valve retrieval and replacement. The 30-day stroke and mortality rates were 11% and 17%, respectively. Ventricular embolization and urgent conversion to open-heart surgery were significantly associated with death during hospitalization (p = 0.017 and p = 0.029, respectively). Likely causes of embolization were identified in 59 patients, with positioning error as the most commonly reported (47%), followed by pacing error (13%). In conclusion, THV embolization occurred early after transcatheter aortic valve implantation. The ascending aorta was the most common site of embolization. Higher 30-day stroke and mortality rates were associated with THV embolization compared with most published series of transcatheter aortic valve implantation outcomes.