Oh...... did that just rupture?!
Presenter
Karim Al-Azizi, M.D., FSCAI, Baylor Scott & White Health, Frisco, TX
Karim Al-Azizi, M.D., FSCAI1, Arthur J Lee, MD2, Rahul Sawhney, DO2, Katherine Brooks Harrington, M.D.2, Justin Schaffer, MD2, William Brinkman, MD2, Molly Szerlip, M.D., FSCAI3 and Srini Potluri, M.D., FSCAI4, (1)Baylor Scott & White Health, Frisco, TX, (2)Baylor Scott & White The Heart Hospital - Plano, Plano, TX, (3)Baylor Scott & White The Heart Hospital - Plano, Richardson, TX, (4)Baylor Scott & White The Heart Hospital - Plano, Frisco, TX
Keywords: Structural Heart Disease (SHD)
Title:
Oh.... Did that just rupture?
Introduction
Transcatheter valve implantation (TAVI) with the balloon expandable prosthesis is widely used. With challenging anatomies, balloons may interact with calcified aortic root complex, and may interfere with the balloon, or cause its rupture. Device retrieval post balloon rupture may be difficult, and cause vascular complications. We report 2 cases of a novel technique of retrieving the device without vascular injury with good outcomes.
Clinical Case
Case 1 : 70 yr old lady with severe symptomatic aortic stenosis deemed high risk for surgery per the Heart Team, referred for a TAVI with a 26 mm Sapien 3 Ultra valve via the transfemoral approach. Procedure was conducted in the usual fashion, but during the deployment of the valve, the balloon ruptured at almost 70% of the valve deployment. On balloon retrieval, the ruptured balloon could not be retrieved in the sheath to be removed from the body. The device was then parked in the descending aorta. Subsequently a contralateral access was obtained and a 14 fr dry seal was inserted. A snare is then inserted in a catheter in the descending aorta. The system was then externally cut and separated from the balloon. The snare was used to grab the cone or tip of the balloon and was then retrieved in the contralateral iliac into the dry seal sheath and the system was introduced through the right transfemoral artery and removed from the left transfemoral access. Angiography revealed patent iliacs and femorals bilaterally with no evidence of vascular dissection or perforation. Both sides achieved good hemostasis with perclose devices. Patient was discharged home the next day. Valve hemodynamics were good with no PVL or increased gradients. Case 2 : 92 yr old gentleman with severe symptomatic aortic stenosis deemed high risk for surgery per the Heart Team, referred for a TAVI with a 29 mm Sapien 3 Ultra valve via the transfemoral approach. Patient has significant peripheral vascular disease, so the right common iliac artery was planned to be dilated with lithotripsy to facilitate sheath insertion. Similar to the previous case, procedure was conducted in the usual fashion, but during the deployment of the valve, the balloon ruptured at almost 80% of the valve deployment. On balloon retrieval, the ruptured balloon could not be retrieved in the sheath to be removed from the body. Similar to the above case, the device was retrieved. Angiography revealed patent iliacs and femorals bilaterally with no evidence of vascular dissection or perforation. Both sides achieved good hemostasis with perclose devices. Patient was discharged home the next day. Valve hemodynamics were good with no PVL or increased gradients.
Discussion
Managing complications during valve deployment is important. Balloon rupture may cause significant vascular complications on retrieval or may require a femoral cut down due to the disruptive nature of the damaged balloon and delivery system. We report a trasncathert percutaneous approach in retrieving rupture balloon catheters post deployement of trasncatheter valve implantaiton.