Unexpected and Unusual Case of Aortic Annulus Rupture and VSD after Balloon Expandable TAVI.
Presenter
Hassan Ashraf, MD, The University of Texas Health Science Center at Houston, Houston, TX
Hassan Ashraf, MD, The University of Texas Health Science Center at Houston, Houston, TX
Title:
Unexpected and Unusual Case of Aortic Annulus Rupture and VSD after Balloon Expandable TAVI.
Introduction:
Transcatheter aortic valve implantation carries the rare but important risk of aortic annulus rupture. Here we describe a case of an aortic annulus rupture extending sub-annular as well as into the sinus of Valsalva after TAVI in a patient declining in cardiogenic shock.
Clinical Case:
47-year-old male with newly diagnosed heart failure was admitted in class IV heart failure syndrome to an outside hospital. He was found to have severe aortic stenosis of type 0 bicuspid valve, a dilated left ventricle of 6 cm, mean gradient of 47 mmHg across the aortic valve, and an ejection fraction of 10-15%. He was started on milrinone infusion to assist diuresis and transferred to our institution. He had severely elevated biventricular end diastolic pressures on arrival for which an IABP was placed for stabilization. He was sliding on IABP and given his condition and STS risk of mortality 4.2%, decision was made to proceed with high risk TAVI. His calcium score was >4000 mm3. After balloon expanded valve deployment, an aortic root angiogram demonstrated contrast reflux into the right ventricle, and shortly after, the patient went into PEA arrest. Immediate CPR was performed, and he was placed on peripheral VA-ECMO. TEE revealed an aortic root perforation communicating with the RV and the patient was emergently taken to the operating room. He was found to have complete destruction of the aortic anulus extending superior through the sinus just to the ostia of the right coronary artery as well as a sub-annular VSD extending posteriorly through the RV outflow tract. His VSD was repaired with a bovine pericardial patch, his root was replaced, and a surgical valve was inserted. While he was able to wean from VA-ECMO to Impella support with improvement in LVEF, his post-operative course was complicated by evidence of liver laceration and intra-abdominal bleeding from CPR. Severe liver failure with sepsis led to progressive vasodilatation, hypotension, and eventually death 4 weeks after TAVI.
Discussion:
Aortic annular rupture is among the most serious TAVI complications and carries a high mortality rate. While TAVI in bicuspid aortic valves is not associated with a higher incidence of annular rupture, the calcium distribution on CT signals a very high risk for such a complication. Societal guidance to proceed with TAVI vs. SAVR in dilated LV and shock patients is lacking, and our preference is to avoid SAVR if at all possible. Despite the complication, the patient hemodynamic profile improved from a cardiac perspective but succumbed to liver failure.