International Journal of Cardiology 171 (2014) 88–100
Contents lists available at ScienceDirect
International Journal of Cardiology j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j c a r d
Letters to the Editor
Acute aortic regurgitation and hemodynamic collapse after balloon aortic valvuloplasty Sasa Loncar, Gidon Perlman, David Planer, Yuval Meroz, Dan Gilon, Chaim Lotan, Haim D. Danenberg ⁎ Department of Cardiology, Hadassah Hebrew University Medical Center, Jerusalem 91120, Israel
a r t i c l e
i n f o
Article history: Received 20 August 2013 Accepted 23 November 2013 Available online 4 December 2013 Keywords: Aortic stenosis Balloon aortic valvuloplasty TAVI
Balloon aortic valvuloplasty (BAV) first introduced by Cribier in 1985 [1] promptly enlarges the aortic valve orifice, reduces the transvalvular gradient and alleviates symptoms. The early interest in BAV declined quickly mainly because its immediate hemodynamic and symptomatic gains are not durable. Transcatheter Aortic Valve Implantation (TAVI) provides a more durable alternative to patients with severe AS and poor surgical candidacy. BAV became an integral initial part of TAVI. BAV is also associated with procedural complications and is thus reserved for the extremely sick and frail patients [2]. Serious adverse events were reported in 16%, with very poor long term survival and mortality up to 50% within six months of follow-up [3]. Procedural mortality rate range from 1% to 3% [4] and severe aortic insufficiency has ranged from 1% to 2% [5,6]. The present case series describes the incidence of acute aortic regurgitation (AR) and its clinical presentation and discusses the diagnostic and therapeutic modalities. We reviewed our database of all consecutive patients who underwent BAV as an isolated procedure or as an initial step in TAVI during a five year period (January 2008 to January 2013), for the occurrence of acute procedural AR manifested as hemodynamic collapse immediately after BAV. Hemodynamic collapse was defined as acute deterioration of blood pressure that warranted prompt cardiopulmonary resuscitation. The clinical records and all preprocedural and procedural imaging studies were thoroughly reviewed, searching for predicting factors as well as for diagnostic and therapeutic clues. There were 219 consecutive patients that underwent BAV as part of TAVI (n = 152) or BAV as an isolated procedure (n = 67). There was no difference in age or co-existent morbidities between the two
⁎ Corresponding author. Tel.: +972 2 6776564; fax: + 972 2 6411028. E-mail address: [email protected] (H.D. Danenberg).
groups, but the BAV suffered from higher rate of LV dysfunction (83% vs. 68%) and all its patients were in NYHA class III or IV. Three patients that suffered immediate hemodynamic collapse following BAV were detected and in all of them, acute AR was the presumed diagnosis. In all three cases BAV was performed as part of TAVI. The procedure was performed under conscious sedation with rapid ventricular pacing (180–200 bpm) via a temporary lead placed in right ventricle. In all three cases BAV was performed by transfemoral artery approach, with an 18 Fr sheath already in place. A major support to the diagnosis in all cases was the floating of the pigtail catheter between the aorta and the left ventricle following BAV (Fig. 1). All three patients underwent resuscitation with intubation, mechanical ventilation, cardiac massage and inotropes followed by prompt valve deployment which resulted in immediate recovery and no mortality at 30 days (Table 1). The differential diagnosis of acute hemodynamic deterioration in a patient undergoing BAV includes in addition to acute AR, bleeding to the pericardium and tamponade due to either the stiff wire in the left
Fig. 1. Hemodynamic collapse after BAV. Arrow shows free-floating pigtail catheter prolapsing to stand still non-contracting left ventricle.
Letters to the Editor
89
Table 1 Characteristics of patients with hemodynamic collapse after BAV during TAVI. Variable
Patient 1
Patient 2
Patient 3
Gender–age Concomitant disease Logistic EuroSCORE Annulus diameter, mm LVEF, % Balloon size, mm Implanted valve
Female 74 S/P CABG pulmonary hypertension, chronic renal failure 48 21 32 20 Edwards-Sapien XT
Male 79 S/P CABG pulmonary hypertension, chronic renal failure 23 24 50 20 Medtronic
Female 92 Severe mitral regurgitation n/a 21 30 20 Edwards-Sapien XT
ventricle or the temporary lead in the right ventricle that is used for rapid pacing during valvuloplasty, bleeding from the puncture site for the large bore sheath, perforation of the descending thoracic aorta, aortic valve annular perforation, perforation of membranous interventricular septum, myocardial ischemia due to coronary artery occlusion by either debris or mobilized calcified valve leaflet and acute ischemic stroke due to dislodgment of calcified debris. The diagnosis of acute aortic regurgitation post-BAV can be challenging due to the drastically poor contraction of the overloaded left ventricle. Echocardiography often fails in identifying this disastrous complication due to cardiac standstill and the lack of diastolic flow across the aortic valve. Yet, echocardiography is essential in ruling out tamponade and should be always available when BAV is performed. Supra-aortic injection appeared in our series as highly contributing to diagnosis, ruling out annular rupture and demonstrating massive contrast flow to the left ventricle. The pigtail catheter floating on fluoroscopy between the ascending aorta and the left ventricle appeared as an immediate warning sign in all three cases, even prior to hemodynamic collapse. Thus, operators performing aortic valve dilatations should be well familiar with the “free floating pigtail” sign and the probable need for urgent therapeutic measures upon its appearance. High index of suspicion of aortic valve rupture must be kept in mind during the BAV and TAVI. Prompt diagnosis enables the correct therapy which is an immediate implantation of a prosthetic valve that has to be ready even before BAV. The occurrence of acute aortic regurgitation and hemodynamic collapse in our series is 1.5%. Fortunately, the procedure was part of TAVI and prompt valve deployment successfully restored valve function and stabilized hemodynamics. Yet, several questions need to be addressed: should “BAV alone” be carried out without TAVI or surgical AVR backup? Is BAV really a necessary step during TAVI procedure or the valve can be simply implanted without prior BAV as reported by Grube et al. with the self expandable Medtronic– Corevalve valve system [7]? While further studies are warranted to solve the latter question, we believe that at this time point it is logical to use balloons that are significantly smaller than the annulus when BAV is performed as pre-dilatation prior to TAVI.
0167-5273/$ – see front matter © 2013 Published by Elsevier Ireland Ltd. http://dx.doi.org/10.1016/j.ijcard.2013.11.063
As the use of TAVI is expanding and technical skills are improving, operators are often quick in crossing the aortic valve and starting BAV without having the bioprosthesis loaded and ready for deployment. The reported cases emphasize the need to have a loaded valve ready for deployment prior to balloon inflation. All three patients deteriorated rapidly and CPR was warranted and promptly commenced. Valve deployment was exerted upon short cessation of cardiac chest massage. There were reports about destruction of implanted valves by chest compressions performed during CPR [8] and therefore, chest compressions should be performed with caution. In all of our three cases an immediate clinical improvement was observed upon the new valve deployment. In conclusion, acute AR is an infrequent catastrophic complication of BAV. Prompt diagnosis and exclusion of other pathologies is critical and achieved with fluoroscopy, supra-aortic angiography and echocardiography. Cardiopulmonary resuscitation and catecholamines may convey short-term hemodynamic improvement but the only definitive therapy is prompt valve deployment. References [1] Cribier A, Savin T, Saondi N, et al. Percutaneous transluminal valvuloplasty of acquired aortic stenosis in elderly patients: an alternative to valve replacement? Lancet 1986;1:63–7. [2] Cribier A, Eltchaninoff H, Tron C, et al. Early experience with percutaneous transcatheter implantation of heart valve prosthesis for the treatment of end-stage inoperable patients with calcific aortic stenosis. J Am Coll Cardiol 2004;43:698–703. [3] Ben-Dor I, Pichard AD, Lowell F, et al. Complications and outcome of balloon aortic valvuloplasty in high-risk or inoperable patients. JACC Cardiovasc Interv 2010;3:1150–6. [4] Eltchaninoff H, Cribier A, Tron C, et al. Balloon aortic valvuloplasty in elderly patients at high risk for surgery or inoperable. Immediate and mid-term results. Eur Heart J 1995;16:1079–84. [5] NHLBI Balloon Valvuloplasty Registry Participants. Percutaneous balloon aortic valvuloplasty: acute and 30 day follow-up results in 674 patients from NHLBI Balloon Valvuloplasty Registry. Circulation 1991;84:2383–97. [6] McKay R. The Mansfield Scientific Aortic Valvuloplasty Registry: overview of acute hemodynamic results and procedural complications. JACC 1991;17:485–91. [7] Grube E, Naber C, Abizaid A, et al. Feasibility of transcatheter aortic valve implantation without balloon pre-dilation: a pilot study. JACC Cardiovasc Interv Jul 2011;4(7):751–7. [8] Scherner M, Madershahian N, Strauch J, et al. Transapical valve implantation and resuscitation: risk of valve destruction. Ann Thorac Surg 2011;92:1909–10.
Contents lists available at ScienceDirect
International Journal of Cardiology j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j c a r d
Letters to the Editor
Acute aortic regurgitation and hemodynamic collapse after balloon aortic valvuloplasty Sasa Loncar, Gidon Perlman, David Planer, Yuval Meroz, Dan Gilon, Chaim Lotan, Haim D. Danenberg ⁎ Department of Cardiology, Hadassah Hebrew University Medical Center, Jerusalem 91120, Israel
a r t i c l e
i n f o
Article history: Received 20 August 2013 Accepted 23 November 2013 Available online 4 December 2013 Keywords: Aortic stenosis Balloon aortic valvuloplasty TAVI
Balloon aortic valvuloplasty (BAV) first introduced by Cribier in 1985 [1] promptly enlarges the aortic valve orifice, reduces the transvalvular gradient and alleviates symptoms. The early interest in BAV declined quickly mainly because its immediate hemodynamic and symptomatic gains are not durable. Transcatheter Aortic Valve Implantation (TAVI) provides a more durable alternative to patients with severe AS and poor surgical candidacy. BAV became an integral initial part of TAVI. BAV is also associated with procedural complications and is thus reserved for the extremely sick and frail patients [2]. Serious adverse events were reported in 16%, with very poor long term survival and mortality up to 50% within six months of follow-up [3]. Procedural mortality rate range from 1% to 3% [4] and severe aortic insufficiency has ranged from 1% to 2% [5,6]. The present case series describes the incidence of acute aortic regurgitation (AR) and its clinical presentation and discusses the diagnostic and therapeutic modalities. We reviewed our database of all consecutive patients who underwent BAV as an isolated procedure or as an initial step in TAVI during a five year period (January 2008 to January 2013), for the occurrence of acute procedural AR manifested as hemodynamic collapse immediately after BAV. Hemodynamic collapse was defined as acute deterioration of blood pressure that warranted prompt cardiopulmonary resuscitation. The clinical records and all preprocedural and procedural imaging studies were thoroughly reviewed, searching for predicting factors as well as for diagnostic and therapeutic clues. There were 219 consecutive patients that underwent BAV as part of TAVI (n = 152) or BAV as an isolated procedure (n = 67). There was no difference in age or co-existent morbidities between the two
⁎ Corresponding author. Tel.: +972 2 6776564; fax: + 972 2 6411028. E-mail address: [email protected] (H.D. Danenberg).
groups, but the BAV suffered from higher rate of LV dysfunction (83% vs. 68%) and all its patients were in NYHA class III or IV. Three patients that suffered immediate hemodynamic collapse following BAV were detected and in all of them, acute AR was the presumed diagnosis. In all three cases BAV was performed as part of TAVI. The procedure was performed under conscious sedation with rapid ventricular pacing (180–200 bpm) via a temporary lead placed in right ventricle. In all three cases BAV was performed by transfemoral artery approach, with an 18 Fr sheath already in place. A major support to the diagnosis in all cases was the floating of the pigtail catheter between the aorta and the left ventricle following BAV (Fig. 1). All three patients underwent resuscitation with intubation, mechanical ventilation, cardiac massage and inotropes followed by prompt valve deployment which resulted in immediate recovery and no mortality at 30 days (Table 1). The differential diagnosis of acute hemodynamic deterioration in a patient undergoing BAV includes in addition to acute AR, bleeding to the pericardium and tamponade due to either the stiff wire in the left
Fig. 1. Hemodynamic collapse after BAV. Arrow shows free-floating pigtail catheter prolapsing to stand still non-contracting left ventricle.
Letters to the Editor
89
Table 1 Characteristics of patients with hemodynamic collapse after BAV during TAVI. Variable
Patient 1
Patient 2
Patient 3
Gender–age Concomitant disease Logistic EuroSCORE Annulus diameter, mm LVEF, % Balloon size, mm Implanted valve
Female 74 S/P CABG pulmonary hypertension, chronic renal failure 48 21 32 20 Edwards-Sapien XT
Male 79 S/P CABG pulmonary hypertension, chronic renal failure 23 24 50 20 Medtronic
Female 92 Severe mitral regurgitation n/a 21 30 20 Edwards-Sapien XT
ventricle or the temporary lead in the right ventricle that is used for rapid pacing during valvuloplasty, bleeding from the puncture site for the large bore sheath, perforation of the descending thoracic aorta, aortic valve annular perforation, perforation of membranous interventricular septum, myocardial ischemia due to coronary artery occlusion by either debris or mobilized calcified valve leaflet and acute ischemic stroke due to dislodgment of calcified debris. The diagnosis of acute aortic regurgitation post-BAV can be challenging due to the drastically poor contraction of the overloaded left ventricle. Echocardiography often fails in identifying this disastrous complication due to cardiac standstill and the lack of diastolic flow across the aortic valve. Yet, echocardiography is essential in ruling out tamponade and should be always available when BAV is performed. Supra-aortic injection appeared in our series as highly contributing to diagnosis, ruling out annular rupture and demonstrating massive contrast flow to the left ventricle. The pigtail catheter floating on fluoroscopy between the ascending aorta and the left ventricle appeared as an immediate warning sign in all three cases, even prior to hemodynamic collapse. Thus, operators performing aortic valve dilatations should be well familiar with the “free floating pigtail” sign and the probable need for urgent therapeutic measures upon its appearance. High index of suspicion of aortic valve rupture must be kept in mind during the BAV and TAVI. Prompt diagnosis enables the correct therapy which is an immediate implantation of a prosthetic valve that has to be ready even before BAV. The occurrence of acute aortic regurgitation and hemodynamic collapse in our series is 1.5%. Fortunately, the procedure was part of TAVI and prompt valve deployment successfully restored valve function and stabilized hemodynamics. Yet, several questions need to be addressed: should “BAV alone” be carried out without TAVI or surgical AVR backup? Is BAV really a necessary step during TAVI procedure or the valve can be simply implanted without prior BAV as reported by Grube et al. with the self expandable Medtronic– Corevalve valve system [7]? While further studies are warranted to solve the latter question, we believe that at this time point it is logical to use balloons that are significantly smaller than the annulus when BAV is performed as pre-dilatation prior to TAVI.
0167-5273/$ – see front matter © 2013 Published by Elsevier Ireland Ltd. http://dx.doi.org/10.1016/j.ijcard.2013.11.063
As the use of TAVI is expanding and technical skills are improving, operators are often quick in crossing the aortic valve and starting BAV without having the bioprosthesis loaded and ready for deployment. The reported cases emphasize the need to have a loaded valve ready for deployment prior to balloon inflation. All three patients deteriorated rapidly and CPR was warranted and promptly commenced. Valve deployment was exerted upon short cessation of cardiac chest massage. There were reports about destruction of implanted valves by chest compressions performed during CPR [8] and therefore, chest compressions should be performed with caution. In all of our three cases an immediate clinical improvement was observed upon the new valve deployment. In conclusion, acute AR is an infrequent catastrophic complication of BAV. Prompt diagnosis and exclusion of other pathologies is critical and achieved with fluoroscopy, supra-aortic angiography and echocardiography. Cardiopulmonary resuscitation and catecholamines may convey short-term hemodynamic improvement but the only definitive therapy is prompt valve deployment. References [1] Cribier A, Savin T, Saondi N, et al. Percutaneous transluminal valvuloplasty of acquired aortic stenosis in elderly patients: an alternative to valve replacement? Lancet 1986;1:63–7. [2] Cribier A, Eltchaninoff H, Tron C, et al. Early experience with percutaneous transcatheter implantation of heart valve prosthesis for the treatment of end-stage inoperable patients with calcific aortic stenosis. J Am Coll Cardiol 2004;43:698–703. [3] Ben-Dor I, Pichard AD, Lowell F, et al. Complications and outcome of balloon aortic valvuloplasty in high-risk or inoperable patients. JACC Cardiovasc Interv 2010;3:1150–6. [4] Eltchaninoff H, Cribier A, Tron C, et al. Balloon aortic valvuloplasty in elderly patients at high risk for surgery or inoperable. Immediate and mid-term results. Eur Heart J 1995;16:1079–84. [5] NHLBI Balloon Valvuloplasty Registry Participants. Percutaneous balloon aortic valvuloplasty: acute and 30 day follow-up results in 674 patients from NHLBI Balloon Valvuloplasty Registry. Circulation 1991;84:2383–97. [6] McKay R. The Mansfield Scientific Aortic Valvuloplasty Registry: overview of acute hemodynamic results and procedural complications. JACC 1991;17:485–91. [7] Grube E, Naber C, Abizaid A, et al. Feasibility of transcatheter aortic valve implantation without balloon pre-dilation: a pilot study. JACC Cardiovasc Interv Jul 2011;4(7):751–7. [8] Scherner M, Madershahian N, Strauch J, et al. Transapical valve implantation and resuscitation: risk of valve destruction. Ann Thorac Surg 2011;92:1909–10.
