Figure 1. Severe acute aortic regurgitation post-valvuloplasty..

Figure 2. Rapid 25 mm Portico valve implantation (Abbott), initially low, and then moved into the ri...

Figure 3. Patient in cardiac arrest. Resuscitation maneuvers started. The Portico valve was implante...

Figure 4. Image of severe pericardial effusion with right-sided chamber collapse.

Figure 5. Final control test confirming the presence of mild aortic regurgitation.

INTRODUCTION

Transcatheter aortic valve implantation (TAVI) is now a standard procedure widely accepted for the management of patients with symptomatic severe aortic stenosis who are not eligible for surgery, with high or intermediate surgical risk or who refuse to undergo surgery. According to the Partner clinical trial, in women, the 2-year results are better compared to conventional surgery.1 Despite being widely accepted as a therapeutic alternative and the greater experience gained by the centers, there are still associated complications. Most of them can jeopardize the patient.

We present the case of a complicated TAVI procedure in a female patient due to acute pericardial tamponade, one of the possible most serious complications associated with this procedure, and also acute aortic regurgitation after balloon angioplasty. Although several temporary hemodynamic support devices are available, we describe our successful approach to this case managing pericardial effusion complications and problems associated with the immediate deployment of the self-expanding valve during external cardiac massage and cardiopulmonary resuscitation maneuvers. Both extremely rare complications when we are dealing with self-expanding valves.

With this presentation, our objective is to send a message to those who may be facing the same catastrophic complications described here.

CASE REPORT

This is the case of an 86-year-old woman who was admitted to receive TAVI due to severe aortic stenosis with previous episodes of exertional dyspnea and angina. The patient’s past medical history showed no signs of syncope. Present medication: levothyroxine 75 mg, omeprazole, aspirin, diosmin, vitamin D, clonazepam 0.5 mg, escitalopram 10 mg, and rosuvastatin 10 mg. The patient’s past medical history included dyslipidemia, hypothyroidism, uterine fibroma surgery, multiple trauma surgeries (knee, shoulder), and Carpal tunnel syndrome. Upon admission, the patient showed a eupneic breathing pattern at rest (with a rate of 14 breaths per minute), blood pressure of 130/60 mm Hg, and pulse of 68 beats per minute.

The patient showed no jugular venous distension or displaced apex beat. Preserved first heart sound and reduced second heart sound. Presence of an intense systolic heart murmur in the aortic area radiating towards the carotid arteries. EKG: sinus rhythm with axis deviated to the left. Presence of severe left ventricular hypertrophy with deformation pattern. The transthoracic echocardiogram performed revealed the present of a heavily calcified aortic valve. The continuous-wave Doppler ultrasound measured a maximal velocity of > 4.5 m/second, and the modified Bernoulli equation suggested a maximal instantaneous gradient > 90 mmHg. Mild aortic regurgitation was present in the Doppler signal. The valve area was estimated at 0.7 cm2 using the equation of continuity. Left ventricular function was normal, the EF was 64% although with a hypertrophic wall. The pulmonary artery systolic pressure was 35 mmHg. There were no signs of thrombus.

The computed tomography (CT) scan confirmed the feasibility of the transfemoral approach and a short diameter of the aortic annulus (19.2 mm), and a long aortic annulus diameter of 24.8 mm, an annular perimeter of 69.3 mm, and an annular area of 370.2 mm. The coronary angiography showed no signs of coronary artery disease. Based on these findings, a decision was made to implant a 25 mm Portico valve. The TAVI procedure was planned with a minimalist approach. The right femoral vein was used to implant the pacemaker and the balloon, the left femoral artery was used for pigtail catheter insertion, and the right femoral artery was used to access the valve.

A small dissection was seen via right femoral access that required the use of a 0.014 in Floppy coronary guidewire and a 6-Fr JR guide catheter. Afterwards, a Cordis® AL2 catheter (Cordis - a Cardinal Health Company Santa Clara, CA, United States) was used followed by a straight-tipped Cook hydrophilic guidewire (Cook Bloomington, IN United States) towards the left ventricle. After inserting this catheter into the LV, it was exchanged for a Safari® guidewire (Boston Scientific Marlborough, MA, United States) that was properly positioned following the JR and pigtail catheter exchange. Valvuloplasty was performed with a 20 mm x 4 mm Atlas® balloon (Bard Tempe, AZ, United States). The control aortography showed severe acute aortic regurgitation as seen on figure 1. Severe hypotension with extreme bradycardia followed by cardiac arrest occurred that required external cardiac massage. Therefore, it was decided to implant Abbot’s 25 mm Portico heart valve (St. Jude Medical, St. Paul, MN, United States) while performing the cardiopulmonary resuscitation maneuvers (figures 2 and 3). Since the echocardiography confirmed the presence of severe pericardial effusion with right-sided chamber collapse and progression to shock, it was decided to perform pericardial drainage (figure 4) by draining 360 mL of bloody pericardial fluid was that were administered to the patient through autologous blood transfusion. Blood was sparkling red suggestive of arterial origin. After implantation and drainage, the patient’s clinical course gradually improved. The final control test confirmed the presence of mild aortic regurgitation (figure 5). During the hospital stay, the patient developed atrial fibrillation that required amiodarone, and thrombocytopenia that required the withdrawal of enoxaparin and clopidogrel. Drainage was removed 24 hours later.

The patient was discharged from the hospital after 5 days with no changes in her EKG. The presence of NYHA FC I-II dyspnea, mild aortic regurgitation (on the Doppler echocardiography), and normal sinus rhythm (on the EKG) was confirmed at the 6-month follow-up.

DISCUSSION

We presented the case of simultaneous doble complications of severe aortic regurgitation and severe pericardial effusion in a female patient during self-expanding valve implantation and analyzed the possible causes of death and complications associated with TAVI.

In order to identify the causes of death during the TAVI procedure and at the 1-month follow-up, 12 studies and 1223 patients were studied. The mortality rate during the procedure was 2.3%.2 During the procedure, the most common causes of death were cardiac tamponade (39%), heart failure (21%), cardiac arrest (18%), and vascular and/or hemorrhagic complications (18%). A comparison was drawn between patients treated with the CoreValve (Medtronic, Minneapolis, MN, United States) and those treated with Edwards valves (Cribier-Edwards, Edwards-SAPIEN or SAPIEN XT valves, Edward Lifesciences, Irvine, CA, United States) that gave the following results: deaths due to vascular and hemorrhagic complications at the 1-month follow-up were less common with the self-expanding valve (3% vs 22%, respectively; P = .019). However, deaths due to cardiac tamponade (26% vs 6%, respectively; P = .019), and aortic regurgitation (10% vs 0%, respectively; P = .03) were more common with the self-expanding valve.

Sudden and unexplained hypotension is often the first indicator of a significant complication and should be an immediate cause to exclude the following 5 main conditions: retroperitoneal hemorrhage due to access site rupture, aortic dissection or rupture, pericardial tamponade, coronary ostia obstruction or severe acute aortic regurgitation.3 In most cases, these conditions can be treated rapidly using the percutaneous approach. However, at times, open heart surgery may be required. The TAVI team should remain alert to recognize and diagnose severe intraprocedural hypotension. Cardiac tamponade during TAVI is not common; instead, it is associated with high rates of mortality, especially when left side structures are affected as it was our case here.4 In a study of patients who suffered cardiac tamponade during or after TAVI between 2007 and 2012, a total of 17 patients (4.3%) showed cardiac tamponade. Mean age was 82.3 ± 3.7 years, and most patients were women. The causes of cardiac tamponade were right ventricular perforation due to temporary pacemaker (52.9%), annular rupture or aortic dissection (23.5%), and left ventricular free wall rupture due to rigid guidewires or catheters (23.5%). Death occurred in 4 patients (23.5%), all with cardiac tamponade due to a lesion in the left ventricle or the aorta. Most patients (82.4%) showed persistent cardiac tamponade during the procedure. Due to the potentially serious complications, all these procedures require the participation of a team of clinical cardiologists, intensivists, interventional cardiologists, and cardiovascular surgeons, the so-called heart team.5 In a large volume center, TAVIs were performed using a self-expanding valve or a balloon too via transfemoral and transapical access. Intraprocedural complications that required intraoperative bailout maneuvers were studied: 7.6% experienced major intraoperative complications, 2.8% required emergency crossover to surgery. Complications included valve embolization/migration (17%), severe aortic regurgitation (12%), and ruptured aortic root (5%). They required the immediate implantation of a second valve or crossover to surgical aortic valve replacement. Sternotomy and surgical hemostasis were performed in 5 patients (13%) with perforation due to a rigid guidewire in the left ventricle followed by cardiac tamponade. Coronary obstruction (15%) required an emergency percutaneous coronary intervention in 6 patients. at the 30-day follow-up, the all-cause mortality rate was 31.4% in patients with intraprocedural complications and 38.5% in those who crossed over to surgery.

Women and patients with a past medical history of coagulopathy have a higher risk of significant pericardial complications during TAVI. Regarding the procedures performed in the United States between 2012 and 2014, the chances of developing cardiac tamponade, pericardiocentesis or pericardial window were 2.29 times higher in women and 1.60 times higher in patients with coagulopathy.6 On the other hand, patients who had previously undergone myocardial revascularization surgery or who were already carriers of a cardiac implantable electronic device had fewer chances of developing significant pericardial complications during TAVI. Patients who developed pericardial complications had significantly higher chances of dying at the hospital: 24.7% vs 3.3% (OR, 4.91; 95%CI, 2.56-9.43). In general, significant pericardial complications occurred in 1.3% of the patients (from 1.2% to 1.5% over the 3 years studied).

In our case we believe that tamponade was left-sided with a hydrophilic guidewire for access purposes in a patient with a small and heavily hypertrophic ventricle.

The patient’s clinical course was favorable, which rules out the possibility of left ventricular rupture with the Amplatz guidewire.

The technical challenges of the procedure and the complex nature of high-risk patients make the learning curve even more steep always with a potential for unexpected complications.

CONCLUSION

In this patient with severe acute aortic regurgitation and severe pericardial tamponade, valve implantation and pericardial drainage alleviated her condition and eventually saved her life. Simultaneously, CPR and orotracheal intubation were rapidly performed. We have not found the same kind of success we had after the Portico self-expanding valve implantation during the external cardiac massage maneuvers in the medical literature available.

This type of procedure and its possible complications are challenging for the heart team and require experience and expertise to be able to perform emergency maneuvers.

1. Williams M, Kodali SK, Hahn RT, el al. Sex-related differences in outcomes after transcatheter or surgical aortic valve replacement in patients with severe aortic stenosis: Insights from the partner trial (placement of aortic transcatheter valve). J Am Coll Cardiol 2014 Apr 22;63(15):1522-8.

2. Moreno R, Calvo L, Salinas P, et al. Causes of Peri-Operative Mortality after Transcatheter Aortic Valve Implantation: A Pooled Analysis of 12 Studies and 1,223 Patients. Journal of Invasive Cardiology 2011;23(5):180-4.

3. El-Gamel A. Cardiovascular Collapse during Transcatheter Aortic Valve Replacement: Diagnosis and Treatment of the “Perilous Pentad.” AORTA 2014. doi:10.12945/j.aorta.2013.13-027.

4. Rezq A, Basavarajaiah S, Latib A, et al. Incidence, management, and outcomes of cardiac tamponade during transcatheter aortic valve implantation: A single-center study. JACC Cardiovasc Interv. 2012;5:1264-72. doi:10.1016/j.jcin.2012.08.012.

5. Seiffert M, Conradi L, Schirmer J, et al. Severe intraprocedural complications after transcatheter aortic valve implantation: Calling for a heart team approach. Eur J Cardio-thoracic Surg 2013. doi:10.1093/ejcts/ezt032.

6. Ogunbayo GO, Misumida N, Goodwin E, et al. Characteristics, outcomes and predictors of significant pericardial complications in patients undergoing transcatheter aortic valve implantation (TAVI). Am J Cardiol 2019;15;124(2):321-2. doi: 10.1016/j.amjcard.2019.04.036.

Para descargar el PDF del artículo
Acute aortic regurgitation, pericardial effusion, and cardiopulmonary regurgitation during TAVI: double complication and successful implantation of a self-expanding valve

Haga click aquí