Sudden Hypotensive Attack Before During After TAVI InHo

Sudden Hypotensive Attack Before, During & After TAVI In-Ho Chae, MD, Ph. D Seoul National University College of Medicine SNU Bundang Hospital, Cardiovascular Center Korea

In-Ho Chae, M. D, Ph. D. I have no relevant financial relationships.

Case 1. (88/F) C/C DOE - Hypertension and dyslipidemia - Otherwise previously healthy - Developed dyspnea on exertion since 6 months ago - Visited ED for recent aggravation

Echocardiography Eccentric LVH, limited AV opening

Transthoracic Echocardiography Severe AS Vmax= 4. 2 m/s m. PG= 45 mm. Hg AVA by CE= 0. 6 cm 2

Sudden hypotension after Lt femoral puncture failure

Coil embolization

Case 2. (88/M) C/C DOE, orthopnea PMhx right tonsillar cancer, c. T 2 N 2 M 0 stage IV (CCRT (2017. 6. 7. – 7. 28. )) : ECOG scale 0, life expectancy > 1 year HTN, DM, DL, Hypothyroidism Medication Aspirin, sitagliptin, levothyroxine, atorvastatin, oxycodone

STS risk of mortality 5. 34%

Planning device 3 Mensio report from Edwards

Deployment of SAPIENT 3 26 mm ( Nominal : -3. 7% oversizing )

TEE right after valve deployment

Additional ballooning due to mod PVL (1 cc overfill : 0. 5% oversizing ) Aortogram after additional ballooning

Sudden hypotensive attack

Cardiac tamponade Emergent pericardiocentesis Autotranfusion with Cellsaver Surgical conversion

Post-Op At discharge

Severe calcification in TAVR 1. Increased risk of paravalvular leak 2. Increased risk of rupture

Annular rupture in TAVR Reported overall risk : 1% # Risk factors 1) small annulus & aortic root 2) severe calcification in leaflets, annulus, LV outflow tract(LVOT), sinus of valsalva (So. V) 3) severe calcification in bicuspid valves # Signs & symptoms Mostly catastrophic, but sometimes asymptomatic. .

Annular rupture in TAVR • Classification 1. Supra-annular - So. V, coronary ostim, STJ 2. Intra-annular 3. Sub-annular - free wall, AMVL, interventricular septum 4. Combined • Treatment Repair of the lesion + AVR ± MVR or CABG Annular rupture during TAVR. JACC Interv, 2015 Rupture of the device landing zone during TAVI. Circ Cardiovasc Interv, 2012

Annular rupture in TAVR • Detection Immediate suspicion and early decision !! Angiography + echocardiography • Strategies to avoid annular rupture 1) Smaller valve 2) Lower pressure 3) Higher deployment position 4) Avoid reballooning 5) use self-expandable valves 6) consider AVR

Cause of this catastrophic event

Case 3. (80/M) C/C DOE Echo. CG at local clinic : severe AS PMhx : HTN, DM

Baseline femoral angiogram & Post TAVI successful femoral closure

Contralateral closure failure with hypotensive attack

Successful Balloon tamponade