Title
Valve Embolization During STEMI
Introduction
While embolization of a TAVR valve is a rare event, it usually occurs during the initial deployment procedure. Coronary occlusion can happen during time of deployment depending on anatomy, and STEMI post TAVR usually happens within the first month. We present a case of a patient that underwent Evolut Pro Plus valve implantation who had cardiopulmonary arrest 12 hours post procedure after developing an inferior STEMI. During urgent LHC, the valve was iatrogenically embolized to the ascending aorta after a diagnostic catheter became ensnared in one of the valve cells requiring the patient be sent for urgent SAVR.
Clinical Case
A 73-year-old female with severe symptomatic aortic valve stenosis (mean gradient 31 mmHg, aortic valve area 0.7 cm2, peak velocity 3.6 m/sec) multiple comorbidities, an STS Score of 3%, and prior LHC revealing nonobstructive disease was deemed a candidate for TAVR by the heart team. She underwent a26 mm Evolut Pro Plus implantation. The morning after TAVR, the patient had ventricular fibrillation arrest requiring CPR. EKG performed showed inferior STEMI. After ROSC, she was urgently taken to the cath lab where she was found to have 100% occlusion of the distal RCA. She underwent aspiration thrombectomy and successful PCI. During the procedure, a JL 3.5 catheter became snared in one of the cells of the cage of the valve. While attempting to place the back end of a J-wire to unfurl the catheter, the TAVR valve was pulled out of position and embolized to the ascending aorta. Remarkably, the patient remained hemodynamically stable with no critical aortic insufficiency and was urgently taken to the OR for SAVR with a 23mm Edwards Magna Ease. The patient did well post SAVR, fully recovered and was discharged home a week later.
Discussion
Valve embolization is a rare complication of TAVR and is more common at time of valve deployment, within a few months later via migration
1, 2. There is increased risk theoretically with more shallow implantation of the self expanding valve platform. While there is limited data on when a valve is completely expanded and anchored into its position, it is important to realize that recent deployment increases the risk unseating the valve. Coronary occlusion following TAVR implantation may occur by embolization of clot or calcium down a coronary or by obstruction by the TAVR valve leaflets or cage.
2 While there is limited data on STEMIs following TAVR, one study did show that 35% of all STEMIs occurred during the first month following TAVR despite having undergone coronary angiography and revascularization prior.
4 Coronary evaluation and intervention can be more difficult in patients post TAVR. Knowledge of valve design, relation of valve to the coronary ostia, sinuses and STJ anatomy is helpful in predicting the difficulty of coronary engagement.
3 It is also important to understand which catheters/sizes will decrease the likelihood of complications.
3 Algorithms for catheterization and trouble shooting have been proposed to help manage the complexities of evaluating and intervening upon patients who are post TAVR.
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