Author + information
- Received May 2, 2018
- Accepted June 5, 2018
- Published online August 15, 2018.
- Akihisa Kataoka, MD, PhDa,∗ (, )
- Yusuke Watanabe, MD PhDa,
- Fukuko Nagura, MDa,
- Ryuta Okabe, MDa,
- Hideyuki Kawashima, MD, PhDa,
- Makoto Nakashima, MDa,
- Tomohiro Imazuru, MD, PhDb and
- Ken Kozuma, MD, PhDa
- aDepartment of Medicine, Division of Cardiology, Teikyo University School of Medicine, Tokyo, Japan
- bDepartment of Cardiovascular Surgery, Teikyo University School of Medicine, Tokyo, Japan
- ↵∗Address for correspondence:
Dr. Akihisa Kataoka, Department of Medicine, Division of Cardiology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo 173-8606, Japan.
An 89-year-old man with symptomatic severe aortic stenosis underwent 29-mm Evolut R (Medtronic, Minneapolis, Minnesota) implantation under general anesthesia. During the procedure, the Evolut R was deployed using the left subclavian artery approach. However, systemic hypotension persisted. Intraoperative transesophageal echocardiography using the EPIQ7/X8-2t system (Philips Medical Systems, Andover, Massachusetts) instantaneously revealed infolding distortion (Figure 1A) with large proximal flow convergence at the distortion point (Figure 1B), leading to massive paravalvular leakage. Fluoroscopy when changed from the perpendicular to the right anterior oblique view demonstrated infolding distortion extending in the longitudinal direction to the end of skirt (Figure 1C). Subsequently, the heart team performed balloon valvuloplasty using a 20-mm Z-MED balloon (B. Braun Medical, Bethlehem, Pennsylvania) (Figures 1D to 1F, Online Videos 1 and 2), which transformed the infolding distortion into the normal round shape, with reduced proximal flow convergence and no paravalvular leakage (Figures 1G to 1I). Thereafter, the patient’s hypotension normalized.
Some cases have reported CoreValve infolding (1,2), but there are no reports of Evolut R infolding. Transesophageal echocardiography can instantaneously diagnose infolding distortion with valve dysfunction compared with fluoroscopy in the right anterior oblique view. The efficacy of balloon valvuloplasty was also evidenced.
Dr. Watanabe is proctor of transfemoral transcatheter aortic valve replacement for Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received May 2, 2018.
- Accepted June 5, 2018.
- 2018 American College of Cardiology Foundation