Int J Cardiovasc Imaging (2014) 30:1463–1464 DOI 10.1007/s10554-014-0483-z
CASE-IN-POINT
Rare complication of circumflex artery occlusion during transfemoral aortic valve replacement (TAVR) Chirojit Mukherjee • Joergen Banusch Joerg Ender
•
Received: 3 June 2014 / Accepted: 28 June 2014 / Published online: 8 July 2014 Ó Springer Science+Business Media Dordrecht 2014
Abstract Circumflex artery occlusion is an unusual but grave complication that can be intra-operatively challenging to identify. Various modalities of imaging are possible during transfemoral aortic valve replacement (TAVR). Fluoroscopy and/or trans-esophageal echocardiography maybe used for assessment during and after TAVR. Imaging dilemma can cause delay or alter diagnosis. We report a case of an imaging complication during TAVR which might have modified the outcome of the procedure.
Circumflex artery occlusion is unusual but grave complications that can be intra-operatively challenging to identify. Various modalities of imaging are possible for
C. Mukherjee (&) J. Banusch J. Ender Department of Anesthesia and Intensive Medicine, Heart Center, University of Leipzig, Struempellstrasse 39, 04289 Leipzig, Germany e-mail: [email protected] J. Banusch e-mail: [email protected] J. Ender e-mail: [email protected]
intervention planning during transfemoral aortic valve replacement (TAVR) [1]. Fluoroscopy and/or transesophageal echocardiography maybe used for assessment during and after TAVR. A 83 year old male patient with severe aortic stenosis (Pmax/Pmean gradient 85/45 mmHg, aortic valve area 0.4 cm2), COPD and end stage renal failure underwent TAVR with conscious sedation. After balloon valvuloplasty with rapid pacing hemodynamic deterioration was apparent, prompting sudden increase in inotropic support. Immediate control angioplasty seemed normal (A). TTE established a new onset of aortic regurgitation with enlarged left ventricle. As a rescue procedure, 27 mm Corevalve (Medtronic Inc. USA) was successfully deployed but efficacious recovery was not established. After intubation, TEE showed inferior lateral wall motion abnormality (B) and subsequent echocardiographic examination of circumflex artery, revealed occlusion from a clear echogenic material (C, D), which could not be previously diagnosed with fluoroscopy. Selective angiography of left main confirmed the findings (E). Preoperative CT scan however was not performed, which could have been used to assess the relationship between valve plane and coronary artery and further note presence of previous CAD [2]. Successful balloon dilation and coronary stenting (F) renewed flow in the circumflex artery (G) further confirmed by TEE (H). Rising inotropes and lactate initiated IABP and ECMO support. After third postoperative day patient succumbed to the procedure. Early use of TEE combined with data from pre-procedure CT angiography might have prevented this complication. This report highlights the necessity for TEE, pre and intraoperative fluoroscopy during the entire procedure of TAVR, as they are complementary imaging armamentarium for successful patient outcome in hybrid operating room.
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Conflict of interest
Int J Cardiovasc Imaging (2014) 30:1463–1464
None.
References 1. Dill KE, George E, Abbara S et al (2013) ACR appropriateness criteria imaging for transcatheter aortic valve replacement. J Am Coll Radiol 10:957–965
123
2. Leipsic J, Gurvitch R, Labounty TM et al (2011) Multidetector computed tomography in transcatheter aortic valve implantation. JACC Cardiovasc Imaging 4:416–429
CASE-IN-POINT
Rare complication of circumflex artery occlusion during transfemoral aortic valve replacement (TAVR) Chirojit Mukherjee • Joergen Banusch Joerg Ender
•
Received: 3 June 2014 / Accepted: 28 June 2014 / Published online: 8 July 2014 Ó Springer Science+Business Media Dordrecht 2014
Abstract Circumflex artery occlusion is an unusual but grave complication that can be intra-operatively challenging to identify. Various modalities of imaging are possible during transfemoral aortic valve replacement (TAVR). Fluoroscopy and/or trans-esophageal echocardiography maybe used for assessment during and after TAVR. Imaging dilemma can cause delay or alter diagnosis. We report a case of an imaging complication during TAVR which might have modified the outcome of the procedure.
Circumflex artery occlusion is unusual but grave complications that can be intra-operatively challenging to identify. Various modalities of imaging are possible for
C. Mukherjee (&) J. Banusch J. Ender Department of Anesthesia and Intensive Medicine, Heart Center, University of Leipzig, Struempellstrasse 39, 04289 Leipzig, Germany e-mail: [email protected] J. Banusch e-mail: [email protected] J. Ender e-mail: [email protected]
intervention planning during transfemoral aortic valve replacement (TAVR) [1]. Fluoroscopy and/or transesophageal echocardiography maybe used for assessment during and after TAVR. A 83 year old male patient with severe aortic stenosis (Pmax/Pmean gradient 85/45 mmHg, aortic valve area 0.4 cm2), COPD and end stage renal failure underwent TAVR with conscious sedation. After balloon valvuloplasty with rapid pacing hemodynamic deterioration was apparent, prompting sudden increase in inotropic support. Immediate control angioplasty seemed normal (A). TTE established a new onset of aortic regurgitation with enlarged left ventricle. As a rescue procedure, 27 mm Corevalve (Medtronic Inc. USA) was successfully deployed but efficacious recovery was not established. After intubation, TEE showed inferior lateral wall motion abnormality (B) and subsequent echocardiographic examination of circumflex artery, revealed occlusion from a clear echogenic material (C, D), which could not be previously diagnosed with fluoroscopy. Selective angiography of left main confirmed the findings (E). Preoperative CT scan however was not performed, which could have been used to assess the relationship between valve plane and coronary artery and further note presence of previous CAD [2]. Successful balloon dilation and coronary stenting (F) renewed flow in the circumflex artery (G) further confirmed by TEE (H). Rising inotropes and lactate initiated IABP and ECMO support. After third postoperative day patient succumbed to the procedure. Early use of TEE combined with data from pre-procedure CT angiography might have prevented this complication. This report highlights the necessity for TEE, pre and intraoperative fluoroscopy during the entire procedure of TAVR, as they are complementary imaging armamentarium for successful patient outcome in hybrid operating room.
123
1464
Conflict of interest
Int J Cardiovasc Imaging (2014) 30:1463–1464
None.
References 1. Dill KE, George E, Abbara S et al (2013) ACR appropriateness criteria imaging for transcatheter aortic valve replacement. J Am Coll Radiol 10:957–965
123
2. Leipsic J, Gurvitch R, Labounty TM et al (2011) Multidetector computed tomography in transcatheter aortic valve implantation. JACC Cardiovasc Imaging 4:416–429
