Case Report
Ventricular Prosthesis Embolization during Transapical Aortic Valve Implantation: The Role of Transesophageal Echocardiography in Diagnosis and Management

https://doi.org/10.1016/j.echo.2010.06.012Get rights and content

The authors present the case of an 81-year-old patient with severe aortic stenosis who experienced left ventricular embolization of an aortic bioprosthesis during transapical aortic valve implantation. The authors discuss reasons for prosthesis embolization and reinforce the attention to technical details and the widespread use of multimodality imaging techniques. In this context, transesophageal echocardiography appears indispensable in the detection and management of procedure-related complications.

Section snippets

Case Presentation

An 81-year-old man with severe symptomatic aortic valve stenosis and high risk for conventional surgery (logistic European System for Cardiac Operative Risk Evaluation score, 69%; Society of Thoracic Surgeons mortality risk score, 9.9%) was admitted to our institution to be evaluated for TA-AVI. He presented in New York Heart Association class III, stable angina pectoris (Canadian Cardiovascular Society class III), and permanent atrial fibrillation. Risk factors included coronary artery disease

Discussion

Malpositioning of a balloon-expandable aortic valve bioprosthesis followed by ventricular (retrograde) embolization into the LV cavity is a rare but life-threatening complication of TA-AVI. To the best of our knowledge to date, three cases of fatal retrograde prosthesis embolization have been reported in the literature from two series of TA-AVI procedures (n = 556 and n = 407).

Causes for subvalvular embolization during TA-AVI are diverse.6 In our case, two factors may have been operational.

Conclusion

TA-AVI is an innovative technique with the potential to improve quality of life in selected groups of patients, avoiding open surgical replacement of the aortic valve and cardiopulmonary bypass. Nevertheless, TA-AVI is a technically challenging procedure, which presents, with experience growing, a large variety of new but typical complications. Life-threatening events such as subvalvular malpositioning and prosthesis embolization into the left ventricle can occur. During the procedure, guidance

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Cited by (3)

  • Subannular Prosthetic Valve Embolization Complicating Transapical Transcatheter Aortic Valve Implantation: Management Without Sternotomy

    2015, Canadian Journal of Cardiology
    Citation Excerpt :

    The key technical points for salvage include: (1) maintaining guide wire position across the embolized and native valves; (2) attempting embolized device repositioning with balloon inflation3; (3) initiating CPB if deemed required; (4) implanting a correctly sized second device across the valve; and (5) intraventricularly crimping the device to reduce mismatch in size between the apical opening and the device before extrication (see the Key messages with salvage section of the Supplementary Material). There have been 3 published cases to date of transapical extraction of subannular prosthetic valve embolization.2,4,5 To our knowledge, this is the first report of 12-month patient survival after transapical salvage without CPB.

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