Author + information
- Received September 28, 2017
- Accepted October 24, 2017
- Published online February 19, 2018.
- Marco B. Ancona, MDa,∗ (, )
- Daisuke Hachinohe, MDa,
- Francesco Giannini, MDa,
- Paolo A. Del Sole, MDa,
- Damiano Regazzoli, MDa,
- Antonio Mangieri, MDa,
- Vittorio Romano, MDa,
- Azeem Latib, MDa,
- Francesco Ancona, MDb,
- Fabrizio Monaco, MDc,
- Alessandro Castiglioni, MDd,
- Antonio Esposito, MDe,
- Matteo Montorfano, MDa and
- Antonio Colombo, MDa
- aInterventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
- bEchocardiography Unit, San Raffaele Scientific Institute, Milan, Italy
- cAnesthesiology Unit; San Raffaele Scientific Institute, Milan, Italy
- dHeart Surgery Department, San Raffaele Scientific Institute, Milan, Italy
- eRadiology Department, San Raffaele Scientific Institute, Milan, Italy
- ↵∗Address for correspondence:
Dr. Marco B. Ancona, Interventional Cardiology Unit, San Raffaele Scientific Institute, Via Olgettina, 60, 20132 Milan, Italy.
An 87-year-old woman presented with worsening symptoms of heart failure. Echocardiography revealed paradoxical low-flow aortic stenosis (mean gradient 34 mm Hg; aortic valve area 0.9 cm2, indexed stroke volume 31 ml/m2) together with small left ventricular (LV) cavity and septal hypertrophy. The patient was then referred for transcatheter aortic valve replacement. Pre-operative computed tomography scan showed a 64-mm annulus with severe aortic angulation (80°) (Figure 1A). The aortic valve was crossed with Movable-Core wire guide (Cook Medical, Bloomington, Indiana) and Amplatz-Left-1 catheter (Cordis, Milpitas, California) was advanced in the LV and changed for a pigtail: however, it was never possible to advance pigtail and the Safari Small wire (Boston Scientific, Marlborough, Massachusetts) into the LV apex (Figures 1B and 1D, dashed line) with the stiff wire often approaching the mitral valve (Figures 1B, 1E, and 1F, continuous line). During guidewire manipulation into the LV, pericardial tamponade occurred and immediate pericardiocentesis was performed (Figure 1C). Transesophageal echocardiography revealed a perforation of the lateral wall of the LV (Online Video 1). Due to active bleeding, surgical treatment of the perforation was performed.
We believe that this complication occurred because of 3 anatomical conditions, which together caused the guidewire never to reach the LV apex (intended wire position in Figures 1B and 1D, dashed line) but always to point toward the lateral wall of the LV (anticipated true wire position in Figures 1B, 1E, and 1F, continuous line): 1) the increase aortic angle of the aortic valve (Figures 1A and 1B); 2) the small LV cavity together with an hypertrophic basal septum (Figures 1B and 1F, red arrow); and 3) the unfavorable alignment between the LV and the aorta (Figures 1E and 1F).
Increased aortic angulation has already been showed to negatively impact procedural success following self-expandable prosthesis implantation, mostly because of a greater incidence of paravalvular leak (1). Our case highlights how it should be also a risk factor for LV perforation, especially if associated with aortic-LV misalignment and small, hypertrophic LV. Efforts to fully gain apical position of the pigtail and usage of an extra small pre-shaped Safari wire are possible solutions that may lower the risk of LV perforation.
Dr. Latib has served as a consultant for Medtronic. Dr. Montorfano has served as a proctor for Edwards Lifesciences, Boston Scientific, and St. Jude Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received September 28, 2017.
- Accepted October 24, 2017.
- 2018 American College of Cardiology Foundation