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8.2 Torrential Aortic Regurgitation

The TAVR patient is a small and frail 75-year-old with severe

aortic valve stenosis and a small LV cavity. The aortic valve

is crossed and the standard wire is exchanged for a stiff

Safari wire. Suddenly, the patient’s hemodynamics collapse

without an obvious cause. The rhythm is sinus at 80, but the

blood pressure is 50/30mmHg, and she is in profound respi-

ratory distress. The anesthesiologists perform a rapid

sequence induction and intubation. They are pushing IV epi-

nephrine with little effect. The decision is made to inject 25

mcg of epinephrine directly into the aortic root via the pigtail

catheter in the non-coronary sinus which results in a mild

improvement in the blood pressure. Echocardiography shows

severe aortic regurgitation thought to be secondary to the

wire crossing. The LV wire is hugging the outer curve of the

aorta and jammed against the non-coronary sinus; it is splint-

ing the aortic valve open. The valve is quickly deployed into

position, and the patient’s hemodynamics improve.

8.2.1 Discussion

Torrential aortic regurgitation (AR) can occur prior to TAVR

deployment due to wire splinting or aggressive pre-TAVR

balloon valvuloplasty. This sometimes also occurs during

TAVR deployment with the use of self-expanding valves.

Wire splinting is often simply corrected by centering the

wire within the aortic valve annulus. The other causes of pre-

deployment AR are really only treated by rapid valve deploy-

ment. The hemodynamic effects of torrential AR are

compounded in patients without pre-existing insufciency

and in those with a very small and non-compliant LV cham-

bers. These patients typically have severe left ventricular

hypertrophy.

The effects of sudden AR are mitigated with the addition

of a mild tachycardia using either pacing or chronotropes.

This will reduce the time spent in diastole, and thus reduce

the regurgitant time, all while awaiting valve deployment.

Severe AR is poorly tolerated in the setting of a sick ventri-

cle. Once ventricular brillation ensues, it is very difcult to

resuscitate these patients. A dilated LV with severe AR is

difcult to debrillate. Initiation of ECMO may be required.

In these cases of AR due to wire placement, with ventricular

arrhythmias and hemodynamic instability, the valve should

be deployed safely and immediately.

8.3 Left Ventricular Wire Perforation

An 82-year-old man with critical aortic stenosis presents for

transfemoral TAVR. He has preserved LV function and

severe ventricular hypertrophy. Vascular access is straight-

forward, but the valve is crossed with some difculty. After

measuring the intracavitary pressures, the surgeon places a

Safari wire into the LV cavity with a normal curve at the

apex. The systolic blood pressure immediately drops, and the

patient becomes anxious and tachypneic. Aortic root injec-

tion shows torrential aortic insufciency. The wire is hug-

ging the outer curvature of the arch and ascending aorta and

seems to be pressed against the non-coronary sinus. The wire

is pulled back so that it is centered through the aortic valve—

the AI reduces, and the hemodynamics return to normal. The

TAVR is deployed but the wire looks compressed. It is

removed using a pigtail catheter to protect the vascular struc-

tures. The blood pressure starts to fall and TTE shows an

enlarging pericardial effusion.

8.3.1 Discussion

Perforation of the LV after TAVR is a rare but catastrophic

complication. It is a leading cause of emergency cardiac sur-

gery in these patients [6]. The current incidence of emer-

gency surgery is 0.7%, with LV perforation from guidewires

and annular rupture at deployment accounting for more than

50% of the cases [6]. A stiff wire is needed to guide the

TAVR from the femoral artery into the LV.At the dawn of

TAVR, this was achieved by manually creating a pigtail

curve in a stiff wire (usually Amplatz Super Stiff), but there

are now commercially made stiff wires with a cushioned soft

spiral “pigtail” at the tip for use in TAVR [6, 7].

Risk factors for LV perforation include a small LV cavity,

a hypercontractile ventricle, and a narrow aorto-mitral angle

directing the wire toward the ventricular free wall [8]. In

addition, a tortuous aorta builds a signicant amount of ten-

sion into the delivery system with forward movement of the

valve. The Safari wires come in a range of sizes and should

be selected based on the size of the LV cavity. A careful

watch for the tip of the wire is required to not allow any ten-

sion to build up and push the pigtail wire against the wall of

the LV apex.

If in an injury does occur, it can be fatal, as the wire mac-

erates the LV muscle in patients that are inherently frail [6].

These patients carry an in-hospital mortality rate of greater

than 50% [6]. A percutaneous pericardial drain should be

placed, and once aortic root injection shows no evidence of

rupture, the patient needs to be intubated and resuscitated, in

preparation for surgery. Urgent sternotomy is often required.

It is helpful to use ventricular pacing to control any severe

hypertension that results after the pericardium is opened.

Pledgeted sutures (3/0 polypropylene on an SH needle) are

used to control the bleeding. The location of the injury some-

times involves or is in proximity to a coronary artery. If the

team is unable to control hemodynamics, cardiopulmonary

bypass is needed. An IABP is helpful postoperatively to

reduce LV systolic pressures and allow time for hemostatic

healing.

8 Transcatheter Aortic Valve Replacement

8.4 Coronary Obstruction

A few minutes following deployment of a valve-in-valve

TAVR, the patient becomes hypotensive and requires large

doses of adrenaline. Echocardiography shows marked LV

dysfunction, and there is widespread ST segment elevation.

A high-dose contrast aortic root angiogram shows poor ow

into the left main. The patient’s condition remains unstable

and is intubated, and the team prepares for peripheral V-A

ECMO.The left femoral artery 6 Fr sheath is replaced with

an 18 Fr ECMO cannula over a stiff wire. Similarly, the 6 Fr

sheath in the right femoral vein that was used for temporary

pacing is removed, and a stiff wire is guided into the SVC.A

25 Fr venous cannula is placed into the SVC with imaging

guidance.

Flows of >4L/min are obtained. Interventional colleagues

attempt to wire the left main coronary artery and place a

stent, “snorkeling” out above the sinotubular junction.

8.4.1 Discussion

Occlusion of the coronary arteries during TAVR is a dreaded

complication, with a 30-day mortality of 35% to 40% [9, 10].

It most commonly affects the left main coronary artery

(80%) and occurs within 1hour of the procedure in the vast

majority of cases [9, 10].

The risk factors for coronary occlusion are low coronary

height (<10 mm), tall leaet height, small aortic root (<

28mm), and low sinotubular junction (STJ) [10]. The sur-

geon must be able to assess the anatomy clearly on CT and

provide an accurate risk assessment. If there is indeed a high

likelihood of obstruction, surgical AVR should be considered

if the patient can tolerate surgery.

For inoperable patients, there are two main techniques to

mitigate the risk of obstruction: (1) leaving a stent in the

coronary, ready for deployment [11], or (2) lacerating the

valve leaet—the BASILICA (Bioprosthetic or native Aortic

Scallop Intentional Laceration to prevent Iatrogenic Coronary

Artery obstruction) procedure [12]. The rst method involves

placing a coronary wire into the at-risk coronary artery and

leaving a long stent “parked” in the mid-coronary artery. The

guide catheter is placed just proximal to the coronary ostia.

If the coronary becomes obstructed during valve deploy-

ment, the stent is withdrawn so that it starts above the STJ

and ends within the coronary. It is expanded, thus providing

a “snorkel” for blood to enter the coronary.

A multicenter retrospective review of patients at risk for

coronary obstruction showed that the 3-year cardiac mortal-

ity was lower in those that had a stent placed vs those that

just had a prophylactic wire placed in the coronary artery

(7.8% vs 15.7%) [13]. There were two cases of delayed stent

thrombosis, both in patients that had a self-expanding valve-

in- valve (ViV) TAVR [13]. Of the 93 patients without stent

placement (i.e., no evidence of coronary occlusion intraop-

eratively), there were 4 delayed coronary occlusions, with 3

ViV cases [13].

The second method of prevention is the BASILICA tech-

nique, for which a microcatheter is positioned above the leaf-

let in question and a snare is placed in the LV just underneath

the leaet [12]. A straight wire is then inserted via the micro-

catheter and placed in contact with the aortic valve leaet.

The wire is then electried using radiofrequency to perforate

the leaet and is snared below. This creates a loop from the

microcatheter—through the leaet and then into the snare.

The wire is again electried and pulled through to com-

pletely lacerate the leaet to the free edge. The leaet then

splays apart during systole, but coapts during diastole. In the

initial trial of 30 patients, 13 underwent native valve TAVR

and the other 17 valve-in-valve (ViV) TAVR [12]. The study

reported one death, three strokes, and no cases of coronary

obstruction during the study period following leaet lacera-

tion [12]. A larger registry of 214 patients undergoing leaet

laceration (72.8% of which were ViV TAVR) showed a

30-day mortality of 2.8% and 30-day stroke rate of 2.8%

[14]. In this series, 4.7% suffered partial or complete coro-

nary obstruction [14].

8.5 Paravalvular Leak

An 84-year-old woman presents with severe aortic stenosis

and previous coronary bypass surgery. All grafts are patent.

The aortic root and annulus are severely calcied, with a

large bar of calcium located in the aorto-mitral curtain. After

heart team discussion, a self -expanding valve is selected to

reduce the chance of aortic root rupture. The valve deploy-

ment height is satisfactory, but there is a severe paravalvular

leak at the non-coronary sinus.

8.5.1 Discussion

Paravalvular leak (PVL) is a known complication of TAVR,

though the results are far better with the third-generation

TAVR valves [15]. The fourth-generation balloon- expandable

valves appear to portend even further improvement, but are

still associated with a 10–20% rate of mild paravalvular leak

[16, 17].

A common risk factor for PVL in self-expanding valves is

increased calcium of the valve and aortic root [18]. A thick

calcium ridge prevents the valve from expanding fully and

becoming tightly xed against the surrounding tissue.

Another risk factor is incorrect deployment height relative to

8.5 Paravalvular Leak

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the annulus. Bicuspid valves have a higher rate of paravalvu-

lar leak in most registries, although this may continue to

decrease with newer-generation devices [19].

If the deployment height is satisfactory, then a careful

examination of the prosthesis stent should be conducted with

TTE and uoroscopy to determine whether the valve is fully

expanded or if a focal collapse is present due to immobile cal-

cium. In the rst instance, a balloon aortic valvuloplasty

(BAV) is performed, being aware of the increased risk of

annular rupture and cognizant of any additional risk factors for

this complication. Performing a post-TAVR balloon dilation

aortic valvuloplasty is associated with an increased risk of

stroke [20]. This balloon also has the potential to injure the

porcine valve leaets of a self-expanding valve. There is a risk

of valve embolization in the setting of pulsatility; it is crucial

to ensure extremely reliable and rapid ventricular pacing.

If the TAVR height is unsatisfactory, careful assessment

should be made as to whether the valve is able to be recap-

tured, or if an additional TAVR needs to be deployed at the

correct height. This, of course, carries an increased risk of

coronary obstruction given that the rst TAVR leaets will

subsequently be stented open.

In some instances, signicant post-deployment PVL is tol-

erated in the hybrid room, with the view to re-evaluation on

TTE in the days to follow. In the case of self-expanding

valves, the stent frame continues to expand over the hours and

days following deployment. Thus, mild PVL has the potential

to improve prior to discharge. If a focal leak with persistent

symptoms is present, consideration should be given to use of

a transcatheter occlusion device [21]. The nal option for a

large PVL is open surgery with removal of the TAVR and

native leaets, followed by surgical valve replacement.

8.6 Iatrogenic Ventricular Septal Defect

The 70-year-old TAVR patient has a mild paravalvular leak

which typically would just be monitored. However, this

patient’s express wish for TAVR is to enable her to return to

caring for her dependent husband more quickly. The surgeon

is concerned about the long-term impact of leaving the small

PVL alone. A balloon post-dilation is performed to x the

leak. Unfortunately, angiography shows that now the leak

has worsened and that the left ventricular outow tract has an

additional jet across the septum.

8.6.1 Discussion

While a 2016 systematic review could only identify 18 case

reports of iatrogenic ventricular septal defects after TAVR

[22], another series reported an incidence of up to 1.5% [23].

This complication may be more common than previously

believed. The basis of the anatomic etiology is focal annular

rupture. This extends immediately into the right side or

occurs as a result of delayed rupture of scar tissue from peri-

procedural trauma [24, 25].

A VSD occurs when calcium is directly compressed into

the membranous septum [26]. This can manifest as AV

block, hematoma of the septum, a stula into the septal tis-

sue, or a full-thickness VSD with left to right shunt

(Table8.1) [26].

A number of risk factors have been described, with sub-

annular calcication in the setting of a large prosthesis as the

most concerning (Table8.2) [25]. There are similar risk fac-

tors for annular rupture, and described common characteris-

tics of these patients help delineate those for whom extra

care is required [26].

Management is conservative for small VSDs, and medi-

cal treatment is often successful even in the setting of ini-

tial heart failure symptoms [27]. Serial echo exams will be

required to insure no extension. If increasing heart failure

results, the VSD should be closed either surgically or per-

cutaneously. Percutaneous closure should be the rst

choice if intervention is deemed necessary. The

Amplatzer™ muscular VSD occluder (St. Jude Medical,

St. Paul MN) closure devices have been effective for this

indication [22].

An alternative to treat a very high VSD, which is espe-

cially useful in the setting of a paravalvular leak, is the

deployment of a second valve-in-valve TAVR, deliberately

placed deeper into the left ventricular outow tract to cover

the defect [28].

Table 8.1 Site and effects of subvalvular rupture after TAVR

Site of subvalvular rupture Effects

Free myocardial wall Acute myocardial rupture,

pseudoaneurysm

Underneath the non-coronary

sinus at the anterior mitral

leaet

Shunt from LVOT to LA

Interventricular septum Hematoma, conduction disturbances

(AV block), stula formation

Table 8.2 Risk factors and common characteristics in subvalvular

rupture

Risk factors for VSD Common characteristics

Sub-annular calcication Dialysis

Prosthesis oversizing CKD

Narrow, calcied, oval-shaped annulus Women

Post-dilation after TAVR >20% Hx mitral valve surgery

Heavily calcied AV Chest wall radiation

8 Transcatheter Aortic Valve Replacement

8.7 Valve Embolization

A straightforward transfemoral TAVR in a robust 75-year-

old with excellent peripheral vessels and generous aortic root

anatomy is in the hybrid suite. The balloon-expandable

TAVR is placed across the annulus, and rapid pacing is com-

menced at 180 beats per minute via a femoral transvenous

pacing wire in the right ventricle. Valve deployment is initi-

ated, and at 75% deployment, the pacing wire loses cap-

ture—the heart returns to sinus rhythm with a thump, the

blood pressure rises, and the valve is promptly ejected into

the ascending aorta.

8.7.1 Discussion

Valve embolization occurs in <1% of TAVR cases and is

becoming more infrequent with time [29, 30]. It remains a

potential complication for both self-expanding and balloon-

expandable valves, albeit with different mechanisms.

Balloon-expandable valves tend to eject if there is loss of

pacing capture during deployment, which was the cause of

60% of cases in one recent study [7]. The pacing threshold

must be checked and the position veried, and the pacing

setting should be a mandatory mode—VOO so that there is

no risk of sensing leading to inhibition of pacing. The rate

must also be high enough to abolish any pulsatility in the

arterial waveform. The risk of pacemaker failure and ejection

also occur with any post-deployment balloon aortic valvulo-

plasty in the setting of either balloon-expandable or self-

inating valve. At maximal ination, the balloon becomes

adherent to the prosthesis, so that if there is any ventricular

ejection (such as with loss of pacing), the valve and balloon

are carried out of the annulus and into the ascending aorta.

Embolization of self-expanding valves has been reported

to occur more frequently and entails a slightly different

mechanism, one of malpositioning [30]. In addition to valve

undersizing, a horizontal aortic root makes it quite hard to

line up the proximal portion of the stent with the annulus.

This means that although the valve height appears satisfac-

tory at partial deployment, it can be difcult to predict what

the nal alignment will be on release.

If a valve has ejected, the rst step is to ensure hemody-

namic stability. A self-expanding valve that gets lodged in

the sinotubular junction often results in severe aortic insuf-

ciency and possible coronary obstruction. Balloon-

expandable valves that eject tend to “tumble” in the ascending

aorta quite freely. Approximately 80% of valves embolize to

the aorta, while the remainder are found in the ventricle [30].

The latter more commonly require surgical retrieval (40% vs

<15%) [30]. Embolization was previously the leading cause

of emergency cardiac surgery but now accounts for just

10–15% of cases [6].

The two steps to ensuring a good outcome are (1) snare

the ejected valve and move it distally and (2) prepare a

new valve for deployment. A large snare (20mm) is usu-

ally required, inserted via the secondary arterial access.

This usually means that a third access site (radial artery)

will be required for contrast injection of the aortic root.

Balloon- expandable valves are snared and pulled into the

descending aorta where they will lodge, and self-expand-

ing valves are pulled into the distal ascending aorta.

Unfortunately, valve embolization results in a signi-

cantly higher all-cause mortality at both 30 days and

1year [7, 30]. This event is best avoided through meticu-

lous planning, accurate sizing, proper positioning, and

veried pacing.

8.8 Aortic Root Rupture

A 70-year-old frail woman with severe aortic stenosis is

referred for consideration of TAVR vs surgery. The plan-

ning CT shows a small aortic root and annulus with signi-

cant calcium in the aorto-mitral curtain. TAVR is certainly

justied for the small root here present, as she would surgi-

cally t only 19mm valve without a root enlargement pro-

cedure. A small surgical valve would certainly result in

patient- prosthesis mismatch. A balloon-expandable valve is

selected to minimize a paravalvular leak in the setting of

annular calcium. The case goes smoothly, the valve is

deployed, and the height appears perfect. There are a trivial

posterior jet and no gradient. Suddenly, the patient com-

plains of pain, and the blood pressure begins to fall.

Echocardiography shows a 10mm pericardial effusion, and

aortic root injection conrms contrast extravasation. A per-

cutaneous pigtail drain is placed, but the patient is increas-

ingly unstable and receiving epinephrine on her way to the

operating theater.

8.8.1 Discussion

Aortic root rupture in TAVR is a rare but devastating compli-

cation with a low incidence of 0.5–1.1% and a high mortality

of 50% [26, 31]. The time between the event and hemody-

namic deterioration ranges from immediate to several days,

depending on the injury. Small tears in the annulus are not

always recognized, as they can be sealed by the skirt of the

TAVR itself. These patients present either immediately in the

hybrid suite or postoperatively with sudden hypotension and

chest pain. Immediate echocardiography and aortic root

angiography are indicated. Diagnostic ndings vary. Annular

rupture may also present as a hematoma of the root that

results in the occlusion of a coronary artery. A pericardial

effusion is often present.

8.8 Aortic Root Rupture

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Risk factors for this complication are similar to that of

TAVR VSD and include the presence of a heavily calcied,

small annulus. Oversizing, use of balloon-expandable valves,

frailty, and a small sinotubular junction are also considered

risk factors [26, 31, 32]. The anatomy of the root and loca-

tion of calcium in the landing zone must be carefully

reviewed (Table8.3) [31].

Management of patients with annular rupture depends on

hemodynamic stability [24, 26, 31–33] (Fig.8.1). The stable

patient with a small defect is generally managed with conser-

vative therapy, including correction of coagulopathy and

placement of a pericardial drain if an effusion is present.

These patients will need close monitoring in the ICU and

serial imaging with CTA.

If the aortic root has a large rupture, pericardial drainage

and urgent transfer to the OR are required. While there have

been case reports of aortic rupture treated with a second TAVR

deployed [24, 33], surgery is usually offered if the patient is a

candidate. If the patient is hemodynamically unstable, the sur-

gical team should be ready for femoral- femoral CPB and ster-

notomy. Peripheral bypass assists in regaining some control;

however, many TAVR patients have poor peripheral vessels,

mandating immediate sternotomy and central cannulation.

The type of repair needed is dependent on the site of injury.

Repairing the aortic root starts with identifying the tear pres-

ent in either the annulus or sinotubular junction. This infor-

mation will determine whether repair can be achieved with a

patch (usually bovine pericardium) or a full root replacement

with reimplantation of the coronary arteries.

Table 8.3 Anatomic ndings based on sites of rupture

Supra-annular site Annular site Sub-annular site

Calcication of middle

or upper aortic root

Ellipsoid annulus Calcication in the

LVOT or septum

Flat sinuses of Valsalva Calcication at the

base of cusps

Narrow LVOT

Calcied body or free

edge of cusps

Calcied rim of

annulus

Annular Rupture

Hemodynamics Stable

Unstable Hemodynamics

Pericardial

Effusion

Diagose

Resuscitate

Conservative

Initiate CPB

Place Drain

Valve in Valve

monitoring

Serial imaging

(CTA)

Close monitoring

Optimize

coagulation

Ye s

ECHO

Aortography

Coronary

Angiogram

Give

volume/blood

Inotropes

Consider

IABP and

temporary

pacemaker

Inoperable

Extreme Risk

Reoperation

Hostile chest

Procelain aorta

(fem-fem vs central)

Sternotomy

Removal of TAVR

Repair lesion (patch, root

repair)

AVR

Fig. 8.1 Management of annular rupture post-TAVR

8 Transcatheter Aortic Valve Replacement

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8 Transcatheter Aortic Valve Replacement

Index

Abdominal compartment syndrome, 60–62

Annular rupture, 90, 92–94

Antithrombin III, 11

Aortic dissection, 43–44, 65, 85–86

Aortic insufciency, 14, 15, 43–46, 90, 93

Aortic pseudoaneurysm, 44–46

Aortic root rupture, 91, 93–94

Arteriovenous stula, 30, 83–84

Axillary cannulation, 45, 85, 86

Balloon expandable stents, 82

Cardiac tamponade, 38, 64, 66

Cardiogenic shock, 29, 35, 36, 63

Cardiopulmonary bypass (CPB), 3, 4, 8, 11–26, 36, 43–45, 57, 60, 64,

66, 69, 81, 85, 86, 90

Cerebral malperfusion, 43

Chylothorax, 37, 38

Circumex artery occlusion, 48–50

Colchicine, 39

Cold agglutinin syndrome, 13, 14

Complement activation, 57, 76

Coronary obstruction, 91–93

Coronary sinus rupture, 14–16

Decompressive laparotomy, 61

Diaphragm paralysis, 74

Endoaortic balloon occlusion, 70, 86

Femoral cannulation, 70, 71, 85

Groin complications, 83

Hemi-sternotomy, 4

Hemolysis, 13, 54

Heparin resistance, 11–13

Hepatic failure, 58–60

Hyperbaric oxygen chamber, 20

Hypercoagulability, 76

IgM antibodies, 13, 24

Iliac artery rupture, 89

Inhaled nitric oxide, 58, 62

Intracerebral atherosclerosis, 76

Ischemic optic neuropathy, 75–76

Leaet laceration, 91

Left ventricular rupture, 47

Leriche syndrome, 33, 34

Lung herniation, 6, 7

Lymph leak, 37, 83

Massive air embolism, 19, 20

Median sternotomy, 1, 4, 5, 21, 72

MELD score, 58, 59

Mini-thoracotomy, 5–7, 84, 85

Mitral valve replacement, 46, 47, 54, 62

Paramedian sternotomy, 1, 2

Paravalvular leak (PVL), 46, 91–93

Percutaneous cannulation, 83

Peripheral nerve injury, 72–74

Peripheral vascular disease, 32, 34, 69, 71, 75

Phrenic nerve injury, 73–76

Postoperative bleeding, 6, 8, 12, 38, 60, 65–66

Postoperative myocardial infarction, 35, 36

Post pericardiotomy syndrome, 38

Post sternotomy pain, 78

Pulmonary artery rupture, 62–63

Pulmonary embolism, 11, 58, 64–65, 73

S. K. Balaram, L. Bassin, Cardiac Surgical Complications, https://doi.org/10.1007/978-3-030-71563-2

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

Radial artery spasm, 31, 32

Recurrent laryngeal nerve injury, 76–77

Reoperative cardiac surgery, 7–9, 81

Retrograde cerebral perfusion, 20

Right ventricular dysfunction, 25

Right ventricular perforation, 85

Self-expanding valves, 90–93

Stroke, 6, 19, 69–71, 75, 76, 85, 87, 91, 92

Subadvential hematoma, 44

Thoracic duct, 37, 63

Thoracotomy, 4–8, 45, 63, 77, 82

Tracheal laceration, 2, 3

Transthoracic clamping, 70

Vascular access, 90

Vascular complications, 89

Index

<<< < Предыдущая 1 2 3 4 5 6 7 8 9 1011 / 1111

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