Complication of Valve in Valve TAVR Umang Shah

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Complication of Valve in Valve TAVR Umang Shah, MD Pranay Vaidya, MD Elie Elmann,

Complication of Valve in Valve TAVR Umang Shah, MD Pranay Vaidya, MD Elie Elmann, MD Irfan Admani, MD Hackensack University Medical Center New Jersey

Umang Shah, MBBS I have no relevant financial relationships

Umang Shah, MBBS I have no relevant financial relationships

CC: Ankle swelling, some shortness of breath HPI: 36 year old female with history

CC: Ankle swelling, some shortness of breath HPI: 36 year old female with history of rheumatic heart disease diagnosed at the age of 10 years and bioprosthetic aortic valve replacement (AVR) 9 years ago, came to obstetrician’s office for evaluation for planned delivery. One year after bioprosthetic AVR she had successful delivery of the healthy child. She had poor medical adherence and did not follow up with her cardiologist regularly. Repeat echo over the years did show gradual deterioration of the aortic valve. 9 years after AVR when she was pregnant she was given option of medical termination of pregnancy due to moderate to severe aortic stenosis. She decide to go ahead with the pregnancy. She missed her appointment with cardiologist at week 13 of pregnancy for an echocardiogram.

 • On week 29 she had an echocardiogram, which showed severe aortic stenosis

• On week 29 she had an echocardiogram, which showed severe aortic stenosis with estimated valve area of 0. 5 cm 2 and mean pressure gradient of 79 mm. Hg. As patient was largely asymptomatic at that point, it was planned to deliver in week 34 -35. At 33 weeks and 6 days, she went to obstetrician for the evaluation. She was found to be edematous with elevated jugular venous pulse and significantly decreased physical activity due to shortness of breath. At that point, due to high risk of complications, it was decided to urgently deliver the baby.

PMH: PSH: Rheumatic heart disease diagnosed at 10 years of age Aortic stenosis Bioprosthetic

PMH: PSH: Rheumatic heart disease diagnosed at 10 years of age Aortic stenosis Bioprosthetic aortic valve replacement and mitral valve repair in 2006 Uncomplicated pregnancy in 2007 with planned caesarian section Medical termination of pregnancy due to trisomy 21 in 2012 Allergy: None SH: No tobacco, alcohol or recreational drug use FH: No family history of premature CAD PE: HR 84, BP 120/70, RR 18, 98. 3°F, 96% on room air CV: Regular rate and rhythm, 4/6 systolic ejection murmur, 2/6 diastolic murmur Lungs: Fine crackles heard in bilateral lung fields, no wheezing or rhonchi Neck: Supple, no bruit, distended JV Extremity: Pulses intact bilaterally, 2+ edema

 • Cardiology and cardiothoracic surgery evaluated the patient • She had pulmonary vascular

• Cardiology and cardiothoracic surgery evaluated the patient • She had pulmonary vascular congestion, treatment with diuretics started • Stat echocardiogram showed mean aortic valve pressure gradient of 96 mm. Hg, elevated right ventricular systolic pressure of 49 mm. Hg and estimated left ventricular ejection fraction of 35 -40% • Next day urgent caesarian section was planned • Endotracheal tube placed and general anesthesia given. In anticipation of hemodynamic compromise femoral arterial and venous access obtained • Upon induction patient developed pulseless electrical activity and 2 minutes of CPR performed and ACLS protocol followed with return of spontaneous circulation • Emergent femoral arterial-venous femoral ECMO placed • Patient required significant vasopressor support including epinephrine, norepinephrine and vasopressin

Due to worsening hemodynamics and requirement of significant vasopressors, she was deemed very high

Due to worsening hemodynamics and requirement of significant vasopressors, she was deemed very high risk for the emergent surgical aortic valve replacement. After discussions with valve team it was decided to perform urgent trans-catheter aortic valve replacement

Valve in Valve TAVR

Valve in Valve TAVR

 • Urgent trans-femoral TAVR done using #23 Metronic Core. Valve – Elovut R

• Urgent trans-femoral TAVR done using #23 Metronic Core. Valve – Elovut R valve • Intra-procedural transesophageal echocardiography showed good placement and mild paravalvular regurgitation • Patient continued to be hemodynamically unstable requiring multiple vasopressors • Repeat echocardiogram the next day showed moderate paravalvular regurgitation with two large regurgitant jets • Because of failure to improve hemodynamics, it was decided to do valvuloplasty of the aortic valve with the goal of reducing paravalvular leak • Axillary cut-down was done by vascular surgery for the vascular access and Dacron graft was used for the repair

Paravalvular Aortic Regurgitation

Paravalvular Aortic Regurgitation

 • Valvuloplasty was complicated by device embolization in the • • • ascending

• Valvuloplasty was complicated by device embolization in the • • • ascending aorta Wire for the balloon most likely went through the valve struts and got entrapped during balloon inflation, causing valve embolization upon balloon pullback Valve stayed stable in ascending aorta, one balloon inflation was done to release entrapped wire and balloon There was good antegrade flow to the carotids, subclavian and in the descending aorta and patient remained hemodynamically stable Due valvuloplasty, aortic valve gradient decreased to 50 mm. Hg and there was mild aortic regurgitation Over the next 4 days patient improved hemodynamically. All the vasopressors and ECMO stopped. She was extubated and ultimately she was discharged home on hospital day 17 3 months later she is doing well overall and is scheduled to undergo surgical aortic and mitral valve replacement next month

 • Valve-In-Valve trans-catheter aortic valve replacement has emerged as acceptable alternative to re-do

• Valve-In-Valve trans-catheter aortic valve replacement has emerged as acceptable alternative to re-do open surgery especially in high risk patients • One of the possible complication of this procedure is embolization of the valve in the ascending or descending aorta • Duncan et al. , in the case series of 17 consecutive patient getting valve in valve TAVR, reported 1 case of device embolization • Valve embolization during TAVR is rare but serious complication • Edgar et al. reported case series of 7 patient who had valve embolization and follow up of 3 years. • If effectively managed, these patients have good long term outcome