CE: Tripti; JCM-D-14-00223; Total nos of Pages: 2;
JCM-D-14-00223
Images in cardiovascular medicine
Prosthesis embolization into the left ventricle during transcatheter aortic valve implantation Fabrizio Follisa, Caterina Gandolfoc, Gianluca Santisea, Amerigo Stabilec, Massimo Benedettoc, Giuseppe Cirrincionec, Antonio Arcadipaneb, Luigi Centineob and Marco Follisd Images and movie clips documenting the rare occurrence of a percutaneous prosthesis embolization into the left ventricle are presented. The case outcome and the circumstances leading to the event are discussed. J Cardiovasc Med 2015, 16:000–000 Keywords: percutaneous aortic valve implantation, prosthesis embolization
Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), cDivision of Cardiology ARNAS, Palermo, Italy and dDepartment of Cardiac Surgery, Albert Einstein College of Medicine, New York City, New York, USA Correspondence to Fabrizio Follis, Piazza Castelnuovo 26 A, 90141 Palermo, Italy Tel: +39 091 6127099; fax: +39 091 6665018; e-mail: [email protected] Received 8 April 2014 Revised 25 June 2014 Accepted 20 August 2014
a
Department of Cardiothoracic Surgery, bDepartment of Anesthesiology,
A 69-year-old woman with critical aortic stenosis (mean gradient 46 mmHg), who had already undergone valvuloplasty with a 22 mm balloon a year earlier, was deemed a high-risk candidate for surgical aortic valve replacement, mainly for her lower body morbid obesity (113 kg 160 cm, BMI 44) with associated knee arthritis, which had made her bedridden. The patient was scheduled for transcatheter aortic valve implantation (TAVI). Immediately after transfemoral implantation of a 23 mm Sapien valve (two-step inflation with effective overdrive),
Fig. 2
Fig. 1
Two-dimensional (2D) echo frame showing the prosthesis in the left ventricular outflow tract.
Edwards valve ‘upside down’ inside the left ventricle
Fig. 3
Aortic anulus
Aortic side of the valve
Cine frame showing the reversed valve in the left ventricle.
1558-2027 ß 2015 Italian Federation of Cardiology
Intraoperative picture of removal of prosthesis from the left ventricle.
DOI:10.2459/JCM.0000000000000218
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
CE: Tripti; JCM-D-14-00223; Total nos of Pages: 2;
JCM-D-14-00223
2 Journal of Cardiovascular Medicine 2014, Vol 00 No 00
Fig. 4
Preoperative CT images showing annular dimensions (panel a), sinotubular junction (panel b), valvular calcifications (panel c) and aortic angulation (panel d). CT, computed tomography.
the prosthesis migrated into the left ventricle and reversed itself (Fig. 1). In an attempt to retrieve the prosthesis into the ascending aorta, it was again engaged with a guide-wire, but the native aortic valve could not be crossed (Fig. 2: movie clip 1, [email protected]). Because of hemodynamic instability, the patient was placed on veno-arterial ECMO and transferred to the operating room. The percutaneous prosthesis was removed (Fig. 3) and the aortic valve replaced with a 21 mm bioprosthesis. The postoperative course was complicated by respiratory failure requiring tracheostomy, but she was eventually transferred to a rehabilitation facility in good condition. Prosthesis migration during TAVI has been described before among valve malpositions and embolizations which occur in 1–2% of the cases. Left ventricular embolization of a valve implanted through a transfemoral approach is rare since this usually occurs with the transapical approach.1 The consequences of subvalvular malposition, however, are more serious than that of the supravalvular ones, since the valve can never be retrieved via catheter and the patient must undergo surgery. Critical review of the case described above (Fig. 4) did not reveal undersizing, a small sinotubular junction or
unusual aortic angulation. However, a final adjustment was made (movie clip 2, [email protected]) just before balloon inflation and valve release, since the valve was judged slightly too high. We believe that this maneuver, together with the lack of severe annular calcifications, indeed observed also at surgery, contributed to the subvalvar embolization. Importantly, when this complication occurs, attempts to retrieve the valve are futile, but engaging the prosthesis with the guide-wire in order to stabilize it in the left ventricle (LV) away from the outflow tract can be life-saving. In a recent metaanalysis,2 mortality for patients requiring emergent cardiac surgery during TAVI was close to 70%. Perhaps, the prompt institution of veno-arterial ECMO with early stabilization of hemodynamic parameters contributed to the patients’ good outcome.
References 1
2
Tuzcu EM. Transcatheter aortic valve replacement malposition and embolization: innovation brings solutions also new challenges. Catheter Cardiovasc Interv 2008; 72:579–580. Eggebrecht H, Schmermund A, Kahlert P, Erbel R, Voigtla¨nder T, Mehta RH. Emergent cardiac surgery during transcatheter aortic valve implantation (TAVI): a weighted meta-analysis of 9,251 patients from 46 studies. Eurointervention 2013; 8:1072–1080.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JCM-D-14-00223
Images in cardiovascular medicine
Prosthesis embolization into the left ventricle during transcatheter aortic valve implantation Fabrizio Follisa, Caterina Gandolfoc, Gianluca Santisea, Amerigo Stabilec, Massimo Benedettoc, Giuseppe Cirrincionec, Antonio Arcadipaneb, Luigi Centineob and Marco Follisd Images and movie clips documenting the rare occurrence of a percutaneous prosthesis embolization into the left ventricle are presented. The case outcome and the circumstances leading to the event are discussed. J Cardiovasc Med 2015, 16:000–000 Keywords: percutaneous aortic valve implantation, prosthesis embolization
Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), cDivision of Cardiology ARNAS, Palermo, Italy and dDepartment of Cardiac Surgery, Albert Einstein College of Medicine, New York City, New York, USA Correspondence to Fabrizio Follis, Piazza Castelnuovo 26 A, 90141 Palermo, Italy Tel: +39 091 6127099; fax: +39 091 6665018; e-mail: [email protected] Received 8 April 2014 Revised 25 June 2014 Accepted 20 August 2014
a
Department of Cardiothoracic Surgery, bDepartment of Anesthesiology,
A 69-year-old woman with critical aortic stenosis (mean gradient 46 mmHg), who had already undergone valvuloplasty with a 22 mm balloon a year earlier, was deemed a high-risk candidate for surgical aortic valve replacement, mainly for her lower body morbid obesity (113 kg 160 cm, BMI 44) with associated knee arthritis, which had made her bedridden. The patient was scheduled for transcatheter aortic valve implantation (TAVI). Immediately after transfemoral implantation of a 23 mm Sapien valve (two-step inflation with effective overdrive),
Fig. 2
Fig. 1
Two-dimensional (2D) echo frame showing the prosthesis in the left ventricular outflow tract.
Edwards valve ‘upside down’ inside the left ventricle
Fig. 3
Aortic anulus
Aortic side of the valve
Cine frame showing the reversed valve in the left ventricle.
1558-2027 ß 2015 Italian Federation of Cardiology
Intraoperative picture of removal of prosthesis from the left ventricle.
DOI:10.2459/JCM.0000000000000218
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
CE: Tripti; JCM-D-14-00223; Total nos of Pages: 2;
JCM-D-14-00223
2 Journal of Cardiovascular Medicine 2014, Vol 00 No 00
Fig. 4
Preoperative CT images showing annular dimensions (panel a), sinotubular junction (panel b), valvular calcifications (panel c) and aortic angulation (panel d). CT, computed tomography.
the prosthesis migrated into the left ventricle and reversed itself (Fig. 1). In an attempt to retrieve the prosthesis into the ascending aorta, it was again engaged with a guide-wire, but the native aortic valve could not be crossed (Fig. 2: movie clip 1, [email protected]). Because of hemodynamic instability, the patient was placed on veno-arterial ECMO and transferred to the operating room. The percutaneous prosthesis was removed (Fig. 3) and the aortic valve replaced with a 21 mm bioprosthesis. The postoperative course was complicated by respiratory failure requiring tracheostomy, but she was eventually transferred to a rehabilitation facility in good condition. Prosthesis migration during TAVI has been described before among valve malpositions and embolizations which occur in 1–2% of the cases. Left ventricular embolization of a valve implanted through a transfemoral approach is rare since this usually occurs with the transapical approach.1 The consequences of subvalvular malposition, however, are more serious than that of the supravalvular ones, since the valve can never be retrieved via catheter and the patient must undergo surgery. Critical review of the case described above (Fig. 4) did not reveal undersizing, a small sinotubular junction or
unusual aortic angulation. However, a final adjustment was made (movie clip 2, [email protected]) just before balloon inflation and valve release, since the valve was judged slightly too high. We believe that this maneuver, together with the lack of severe annular calcifications, indeed observed also at surgery, contributed to the subvalvar embolization. Importantly, when this complication occurs, attempts to retrieve the valve are futile, but engaging the prosthesis with the guide-wire in order to stabilize it in the left ventricle (LV) away from the outflow tract can be life-saving. In a recent metaanalysis,2 mortality for patients requiring emergent cardiac surgery during TAVI was close to 70%. Perhaps, the prompt institution of veno-arterial ECMO with early stabilization of hemodynamic parameters contributed to the patients’ good outcome.
References 1
2
Tuzcu EM. Transcatheter aortic valve replacement malposition and embolization: innovation brings solutions also new challenges. Catheter Cardiovasc Interv 2008; 72:579–580. Eggebrecht H, Schmermund A, Kahlert P, Erbel R, Voigtla¨nder T, Mehta RH. Emergent cardiac surgery during transcatheter aortic valve implantation (TAVI): a weighted meta-analysis of 9,251 patients from 46 studies. Eurointervention 2013; 8:1072–1080.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
