Abnormal distortion of aortic corevalve bioprosthesis with suicide left ventricle, aortic insufficiency, and severe mitral regurgitation during transcatheter aortic valve replacement

• Published in: Catheterization and cardiovascular interventions 2016-12, Vol.88 (7), p.1181-1187
• Main Authors: Leya, Ferdinand, Tuchek, J. Michael, Coats, Walter
• Format: Article
• Language: English
• Subjects: aortic annulus; Aortic Valve - diagnostic imaging; Aortic Valve - physiopathology; aortic valve disease; Aortic Valve Insufficiency - diagnostic imaging; Aortic Valve Insufficiency - etiology; Aortic Valve Insufficiency - physiopathology; Aortic Valve Insufficiency - therapy; Aortic Valve Stenosis - diagnostic imaging; Aortic Valve Stenosis - physiopathology; Aortic Valve Stenosis - therapy; Balloon Valvuloplasty; Bioprosthesis; Cardiac Catheterization - adverse effects; Cardiac Catheterization - instrumentation; Cardiac Catheterization - methods; Echocardiography, Doppler, Color; Echocardiography, Transesophageal; elderly patients; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation - adverse effects; Heart Valve Prosthesis Implantation - instrumentation; Heart Valve Prosthesis Implantation - methods; Humans; mitral annular calcification; Mitral Valve Insufficiency - diagnostic imaging; Mitral Valve Insufficiency - etiology; Mitral Valve Insufficiency - physiopathology; Mitral Valve Insufficiency - therapy; Multidetector Computed Tomography; Prosthesis Design; Radiography, Interventional; Recovery of Function; Severity of Illness Index; sigmoid septum; Stroke Volume; transcatheter valve implantation; Treatment Outcome; Ventricular Function, Left; Ventricular Pressure
• ISSN: 1522-1946; 1522-726X
• DOI: 10.1002/ccd.26463

We present a patient with critical degenerative aortic stenosis, mitral annular and aortomitral continuity calcification, and senile sigmoid septal hypertrophy who underwent transcatheter aortic valve replacement using the CoreValve bioprosthesis. Immediately after predilation of the aortic valve (18‐mm balloon), the patient developed severe hypotension and dynamic left ventricular outflow tract (LVOT) obstruction with systolic anterior motion of the anterior mitral leaflet, causing severe mitral regurgitation. After deployment of a 26‐mm bioprosthesis, a transesophageal echocardiogram and left ventriculogram showed that the frame of the bioprosthesis appeared distorted and underexpanded. On the mitral side of the aorta (side of the aortomitral curtain between 12:00 and 3:00, echo short axis view), we found moderate periprosthetic aortic insufficiency with worse mitral regurgitation. The left ventricle was small and hyperdynamic (ejection fraction >85%). The patient soon developed complete heart block, atrial fibrillation, and ventricular tachycardia. She was resuscitated with aggressive intravenous fluids, vasopressors, and an emergently placed atrioventricular sequential pacemaker. We postdilated the 26‐mm bioprosthesis with a 22‐mm Z‐Med balloon and subsequently with a 25‐mm balloon. Each balloon was inflated to its nominal volume and pressure and conformed the nitinol frame of the valve to the net circular shape and expected diameter. However, as soon as each balloon was deflated, the surrounding aortic root anatomy visibly recoiled and the frame returned to its smaller diameter with a distorted shape. A second 26‐mm CoreValve bioprosthesis was then deployed in a “valve‐in‐valve” configuration. Soon after, the patient's hemodynamics improved, her clinical condition stabilized, and she completely recovered. © 2016 Wiley Periodicals, Inc.