Folded, But Not Fooled: A case of TAVR prosthesis infolding detected and successfully addressed peri-procedurally
Presenter
Jacob McAuliffe, MD, Eastern Virginia Medical School, Norfolk, VA
Jacob McAuliffe, MD1, Matthew Summers, MD, FACC2, David Adler, M.D., FSCAI3 and Deepak R. Talreja, M.D.3, (1)Eastern Virginia Medical School, Norfolk, VA, (2)Sentara Cardiology Specialists, Norfolk, VA, (3)Sentara Cardiology Specialists, Virginia Beach, VA
Title:
Folded, But Not Fooled:
A case of TAVR prosthesis infolding detected and successfully addressed peri-procedurally
Introduction:
Transcatheter aortic valve replacement (TAVR) relies on either balloon expandable or self-expanding valve prostheses. Infolding of self-expanding valves is rare, but it’s a well-documented complication after TAVR that significantly increases the rate for prosthesis malfunction and almost always requires subsequent interventional revision. Detection of infolding peri-procedurally is critical but difficult to accomplish in subtle cases.
Clinical Case:
Our patient is a 59-year-old female with no prior past medical history who was admitted for evaluation of recurrent syncope. Over the prior two years, she had at least five witnessed syncopal episodes, which were attributed to dehydration and orthostasis prior to this admission. During her syncopal work up, a transthoracic echocardiogram revealed severe aortic stenosis (AV area 0.41 cm2; mean gradient 88 mmHg; EF 50%). After clinical stabilization, she was discharged with engagement of structural heart and cardiothoracic surgery teams for outpatient consideration of aortic valve replacement. Given no indications for any concurrent surgical intervention, she elected to proceed with TAVR. Her TAVR candidacy workup was significant for two LAD lesions (70% proximal; 50% mid) that were treated with PCI. CTA imaging, along with other diagnostics, demonstrated heavy, eccentric calcification of the aortic valve leaflets and annulus. She was directly re-admitted 10 weeks after her index hospitalization to undergo TAVR. Transfemoral access was obtained without complication and the valve was easily crossed with a straight wire. Balloon valvuloplasty was performed, achieving adequate fluoroscopic dilation. Using rapid ventricular pacing, the valve delivery system (34mm Evolut FX) was advanced through the aortic annulus and deployed. Post-deployment hemodynamics were excellent, however, upon visual inspection under fluoroscopy, there was some concern of asymmetrical expansion of the prosthesis, so the device was withdrawn. Manual inspection of the valve apparatus showed significant infolding. This uncommon mechanical defect was at first attributed to a manufacture defect and a second TAVR device was prepped and deployed. This valve, however, also appeared to deploy asymmetrically on fluoroscopy, so it too was withdrawn; manual inspection showed a similar pattern and degree of infolding. Suspicion now returned toward the remarkably heavy calcification of the aortic annulus, which had appeared sufficiently dilated on fluoroscopy earlier in the procedure. After repeating BAV, a third TAVR device was successfully expanded. TTE and angiography showed a well seated valve with only trivial paravalvular leak.
Discussion:
This case highlights the success of an experienced interventional cardiology team in detecting and addressing prosthetic infolding after noticing a subtle asymmetry on fluoroscopic assessment post deployment. Infolding is a rare complication of TAVR (occurring in less than 1% of cases) but can have devastating clinical consequences. Risk factors associated with infolding include both anatomical (heavy or eccentric calcification, highly elliptical annulus, valve-in-valve deployment, etc.) and device-related factors (large prosthesis size, improper loading, resheathing, etc.). Our patient’s heavy and eccentric calcification pattern was her most prominent risk factor.