Author + information
- Received December 19, 2012
- Accepted February 3, 2013
- Published online June 1, 2013.
- Vijayakumar Subban, MBBS, MD, DM∗∗ (, )
- Alexander Incani, MBBS∗,
- Andrew Clarke, MBBS∗,
- Constantine Aroney, MBBS, MD∗,†,
- Gregory M. Scalia, MBBS, MMSc∗,†,
- James A. Crowhurst, BSc∗,
- Owen Christopher Raffel, MBChB∗ and
- Darren L. Walters, MBBS, MPhil∗,†
- ∗Heart Lung Institute, The Prince Charles Hospital, Brisbane, Queensland, Australia
- †University of Queensland, St. Lucia, Brisbane, Queensland, Australia
- ↵∗Reprint requests and correspondence:
Dr. Vijayakumar Subban, Fellow in Interventional Cardiology, Cardiology Program, The Prince Charles Hospital, Rode Road, Chermside, Brisbane, Queensland, Australia 4032.
An 87-year-old woman with symptomatic severe aortic stenosis, logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) of 20.94%, and Society of Thoracic Surgeons' estimated surgical mortality of 27.4%, underwent transcatheter aortic valve implantation (TAVI). Her transesophageal echocardiogram (TOE) showed a valve area of 0.7 cm2 (peak velocity: 5.3 m/s), an annular diameter of 19 mm, and good left ventricular systolic function. The computed tomography aortogram demonstrated heavily calcified aortic root, leaflets, and annulus (Figs. 1A to 1C), a descending thoracic aortic aneurysm, and small caliber access vessels. The total volume of aortic leaflet calcium was 1,444 mm3. The annulus transverse diameters were a minimum of 20 mm and a maximum of 23 mm, a perimeter of 63 mm, and an area of 290 mm2 (3mensio valves, Medical Imaging BV, Bilthoven, the Netherlands). She underwent TAVI via the transaortic root with a 23-mm Edwards Sapien XT valve (Edwards Lifesciences, Irvine, California). The immediate post-deployment TOE and aortogram showed an expanding hematoma of the posterior aortic root below the left main coronary artery (Figs. 1D and 1E). There was no pericardial effusion or hemodynamic compromise; hence, she was managed conservatively with local digital compression, packing of the mediastinal space with surgical sponges, reversal of anticoagulation, and lowering of systolic blood pressure. She was monitored on the table for 1 h. There was no further expansion of the hematoma (Figs. 1F and 1G). The packing was removed and the sternum closed. She was transferred to the post-operative ward. The patient remained stable and serial echocardiograms showed resolution of the hematoma (Fig. 1H).
Annular rupture is a catastrophic complication of TAVI that occurs in 0.1% to 1% of the patients undergoing this procedure (1). Extensive annular, leaflet, and aortic calcification and implantation of oversized valve prosthesis predispose individuals to rupture, which has exclusively been reported with balloon expandable prosthesis. Careful evaluation of the severity of the calcification and selecting an appropriately sized self-expanding valve in patients with extensive calcification might prevent this serious complication. Intraprocedural TOE may be of great value in the timely recognition of this serious adverse event. Frank rupture results in immediate tamponade and requires urgent surgical intervention. In cases with a transaortic approach where the sternum is open, a contained rupture may be managed with a conservative wait-and-watch policy (2,3).
Dr. Walters has served as an honorary consultant and proctor for Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received December 19, 2012.
- Accepted February 3, 2013.
- American College of Cardiology Foundation
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