Transcatheter Aortic Valve ImplantationReview of the Nature, Management, and Avoidance of Procedural Complications
Jean-Bernard Masson, MD*,
Jan Kovac, MD ,
Gerhard Schuler, MD ,
Jian Ye, MD*,
Anson Cheung, MD*,
Samir Kapadia, MD ,
Murat E. Tuzcu, MD,
Susheel Kodali, MD||,
Martin B. Leon, MD||,
John G. Webb, MD*,*
* Divisions of Cardiology and Cardiac Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, Canada
Department of Cardiology, University Hospitals, Leicester, United Kingdom
Department of Cardiology, Heart Center, Leipzig, Germany
Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
|| Center for Interventional Vascular Therapy, Columbia University Medical Center, New York, New York
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Figure 1 Vascular Injury
(A) Dissection of the right iliac artery. (B) Occlusion balloon (Occlusion Catheter, Boston Scientific, Natick, Massachusetts). (C) Occlusion balloon (Coda Occlusion Balloon Catheter, Cook Medical, Inc., Bloomington, Indiana) inflated in the left iliac artery.
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Figure 4 Apical Pseudoaneurysm
(A) Pseudoaneurysm arising from the left ventricular apex apparent several weeks after a transapical procedure. The black arrow indicates the valved stent. (B) Pseudoaneurysm formation after a local wound infection. Ao = aorta; LV = left ventricle; PA = pseudoaneurysm.
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Figure 5 Embolization
(A) The embolized balloon-expandable valve orientation is maintained by the wire position. (B) The prosthesis is secured in the aorta with no detectable gradient across it.
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Figure 6 Coronary Obstruction and Frame Deformation
(A) Normal flow in the left coronary artery despite the presence of a stent strut at the left main coronary ostium. (B) Oval shape of the transcatheter valve, possibly the result of chest compressions received during a transient hypotension episode.
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Figure 7 Left Main Obstruction
(A) Left main coronary artery occlusion resulting from a bulky leaflet displaced over the ostium. (B) Successful percutaneous intervention restored left coronary flow. (C) In a second patient, calcifications from the native aortic leaflet and left main (arrows) are approximated after valve implantation. (D) At autopsy, the leaflet (not the stent itself) seemed to obstruct the ostium.
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Figure 8 Delayed Mitral Valve Injury
(A) The stent (double arrow) is in contact with the anterior mitral leaflet. Prosthetic valve endocarditis 1 year after implantation associated with perforation of the mitral leaflet at the point of contact (single arrow). (B) Ensuing severe mitral regurgitation. (C) In a second patient, prolapse of the anterior mitral leaflet secondary to chordeal rupture created (D) severe mitral regurgitation several months after the procedure. Ao = aorta; LA = left atrium; LVOT = left ventricular outflow tract.
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Figure 9 Paravalvular Regurgitation
(A) Self-expanding valve implanted too low, resulting in severe paravalvular regurgitation. (B) A second prosthesis was implanted in the correct position (arrows indicate the distal edge of both prostheses). (C) Mild residual paravalvular leak.
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Figure 11 Annulus Rupture
(A) Pre-implantation significant mitral regurgitation (MR) and severe calcification of the aortic annulus and subvalvular tissues. (B and C) After valve implantation, a tear (arrows) is visible at the ventricular edge of the stent, connecting the left ventricular outflow tract and left atrium, with large left ventricular to left atrial shunt. (D) Autopsy proven tear of the anterior mitral curtain.
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