Journal of the American Society of Echocardiography
Case ReportVentricular Prosthesis Embolization during Transapical Aortic Valve Implantation: The Role of Transesophageal Echocardiography in Diagnosis and Management
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
References (8)
- et al.
Results of transfemoral or transapical aortic valve implantation following uniform assessment in high-risk patients with aortic stenosis
J Am Coll Cardiol
(2009) - et al.
Transapical aortic valve implantation: step by step
Ann Thorac Surg
(2009) - et al.
Transcatheter valve implantation for patients with aortic stenosis: a position statement from the European Association of Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI)
Eur J Cardiothorac Surg
(2008) - et al.
Transapical minimally invasive aortic valve implantation: the initial 50 patients
Eur J Cardiothorac Surg
(2008)
Cited by (3)
Subannular Prosthetic Valve Embolization Complicating Transapical Transcatheter Aortic Valve Implantation: Management Without Sternotomy
2015, Canadian Journal of CardiologyCitation 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.
Pre-dismissal surveillance echocardiography second day after TAVR
2012, JACC: Cardiovascular Imaging