A Case of Stanford Type A Aortic Dissection as a Complication of TAVI ; TA-TAVI Conversion as a Troubleshooting

Abstract

We report a successful troubleshooting strategy for the Stanford type A aortic dissection that occurred in a 77-year-old woman during transcatheter aortic valve implantation(TAVI). She underwent percutaneous coronary intervention on 5 previous occasions ; however, her left anterior descending and left circumflex arteries were obstructed, and the right coronary artery(RCA)served as a feeding artery (although the RCA was also moderately stenosed). She was diagnosed with concomitant heart failure secondary to worsening severe aortic stenosis. In view of the low ejection fraction(31%)and severe ischemic heart disease, we initiated percutaneous cardiopulmonary support(PCPS)to maintain adequate systemic and pulmonary circulation. The femoral artery was atherosclerotic ; therefore, the right subclavian artery was selected for arterial access, and the femoral vein was selected for venous access. Intraoperatively, after stabilizing the PCPS, we started to run the system ; however, arterial flow could not be maintained owing to increased arterial pressure. Transeshophageal echocardiography revealed Stanford type A aortic dissection with the entry point at the brachiocephalic artery. The false lumen extended into the ascending aorta up to the level of the sinotubular junction. Fortunately, no coronary artery compression was detected. Aortic dissection-induced afterload elevation led to ineffective valve opening and consequent left ventricular dysfunction. We performed transapical(TA)-TAVI conversion and entry point closure via the TA route as a troubleshooting strategy. The procedure was performed successfully, and the patientʼs postoperative course was uneventful. Jpn. J. Cardiovasc. Surg. 50 : 397-400(2021) Keywords：percutaneous cardiopulmonary support ; aortic dissection ; TA-TAVI conversion ; heart team ; troubleshooting