Aortic Pseudoaneurysm and Hemopericardium After Intentional Bioprosthetic Valve Fracture During Valve-in-Valve Transcatheter Aortic Valve Replacement
Ali Noory, MD, Allegheny General Hospital, Pittsburgh, PA
Ali Noory, MD, Allegheny General Hospital, Pittsburgh, PA
Keywords: Structural Heart Disease (SHD)
Title
Aortic Pseudoaneurysm and Hemopericardium After Intentional Bioprosthetic Valve Fracture During Valve-in-Valve Transcatheter Aortic Valve Replacement Introduction
Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) has been established as a safe and effective approach to treat failed surgical bioprosthetic valves. Intentional bioprosthetic valve fracture (BVF) via balloon valvuloplasty is a novel technique used to decrease patient-prosthesis mismatch (PPM) in ViV TAVR. Clinical Case
79 year old female with a history of bioprosthetic aortic valve replacement (21 mm Soren Mitroflow 2013) and chronic diastolic heart failure was evaluated for progressive dyspnea and volume overload. Transthoracic echocardiography (TTE) revealed severe prosthetic aortic valve insufficiency and stenosis with pannus formation. After multidisciplinary discussion between Cardiology and Cardiothoracic Surgery, plans were made for 23 mm Evolut Pro+ ViV TAVR via transfemoral approach. Prior to valve deployment, intentional fracture of the bioprosthetic valve sewing ring was performed utilizing a 22 mm True balloon. Post-valve deployment TTE revealed an aortic valve mean gradient of 5 mmHg with no paravalvular leak. The patient experienced transient hypotension and was found to have a small to moderate pericardial effusion, with a small amount of drainage achieved via pericardiocentesis. Aortogram revealed no annular rupture, and left ventriculogram revealed no perforation. Repeat TTE showed improvement of effusion with no tamponade physiology. Post-procedural computed tomographic (CT) angiography showed multi-lobed, large pseudoaneurysm off of the left Sinus of Valsalva with hemopericardium. Serial CTs showed persisting flow and enlargement of the pseudoaneurysm. She subsequently underwent redo-aortic valve replacement (21 mm MagnaEase) and aortic annular rupture patch repair. Post-operative course was complicated by pneumonia and respiratory failure requiring tracheostomy, prior to discharge to long-term assisted facility. Discussion
Historically, Mitroflow bioprosthetic valves were considered ideal in patients with small aortic roots, but were prone to early structural valve degeneration. This led to progressive heart failure in this patient, necessitating discussion regarding valve treatment strategy. ViV TAVR is an increasingly used option for patients experiencing failed bioprosthetic valves. Several cohort studies and meta-analyses have shown ViV TAVR to have better short term outcomes and fewer complications (all-cause mortality, stroke, bleeding) when compared to redo surgical aortic valve replacement. However, ViV TAVR has been associated with higher rates of severe PPM, especially in patients with small surgical valves ≤ 21 mm. Strategies to reduce PPM include intentional BVF using balloon valvuloplasty to break the surgical sewing ring, increase effective orifice area, and allow for optimal expansion of the trans-catheter valve. Several multi-center case series have shown BVF resulting in improved hemodynamics with reduced residual valvular gradients post ViV TAVR. Complications such as death, coronary artery obstruction, annular rupture, aortic root injury, and pericardial effusion were low. However, clinical experience with BVF is still early, and the incremental risk of BVF in TAVR is not yet fully understood and warrants further study. Thus, potential complications such as aortic root injury or coronary artery obstruction should be closely monitored. Here, we describe a case of BVF complicated by annular rupture with pseudoaneurysm and hemopericardium requiring surgical repair, despite excellent valve hemodynamics post-transcatheter valve deployment.