Aortic Root Pseudoaneurysm 1 Year After Transapical Aortic Valve Implantation

Abstract

A n 84-year-old woman was admitted to our institution for transapical aortic valve implantation (TAVI) because of severe aortic stenosis coexisting with high-risk clinical conditions. She had a past history of type 2 diabetes mellitus, hypertension, intrinsic asthma, moderate to severe chronic renal insufficiency (Modification of Diet in Renal Disease glomerular filtration rate, 36 mL/min per 1.73 m 2 ), and peripheral atherosclerotic vascular disease involving both iliofemoral arteries. Eighteen months before, she had suffered a non-ST-segment elevation myocardial infarction and was treated with 2 bare metal stents on the middle segment of the left anterior descending coronary artery and the very proximal or ostial segment of the right coronary artery. Aortic stenosis was evaluated as moderate. After 5 months, she developed advanced Mobitz II-type atrioventricular block, and a permanent sequential atrial synchronous ventricular inhibited pacemarker was indicated. Progression of the aortic valve disease was not noted. More recently, she was admitted to another hospital with severe dyspnea, showing signs of acute heart failure on physical examination. Urgent transthoracic echocardiogram disclosed a normal left ventricle with preserved ejection fraction and progression of the severity of the aortic valve stenosis. Because of the very high operative risk, conventional on-pump aortic valve replacement was dismissed.Before TAVI, a complete transesophageal echocardiographic (TEE) study confirmed the presumptive diagnosis of severe aortic stenosis (Figure 1). The findings were those expected for degenerative valvulopathy (severe thickness and calcification of the leaflets and critical reduction of the valve opening), showing normal characteristics of the aortic root. Precise measurement of the aortic annulus was accomplished with TEE to determine the appropriate prosthetic size. A successful procedure with a 23-mm SAAPIEN bovine pericardial valve (Edwards Lifesciences Inc, Irvine, Calif) was performed. Intraoperative TEE and fluoroscopy confirmed only minimal aortic regurgitation. The patient was discharged on the 10th postoperative day in very good condition, with normal function of the bioprosthesis on echocardiography. At 3-and 6-month follow-ups, the patient was in functional class II, and the echocardiograms revealed good function of the valve, with minimal aortic regurgitation observed during both checkups.One year later, the patient presented with angina with atypical characteristics. She was referred again to the echocardiography laboratory to assess prosthetic function and coronary stent patency with pharmacological stress. The echocardiogram under basal conditions revealed a pseudoaneurysm in the anterior wall of the aortic root (Figure 2A). Immediate TEE with the use of a 3-dimensional TEE probe (Philips, Andover, Ma) allowed us to better delineate the pseudoaneurysm ( Figure 2B). The pseudoaneurysm caused compression of the main left coronary artery and was therefore responsible for the angina (Figure 3 and...

Prosthesis Oversizing in Balloon-Expandable Transcatheter Aortic Valve Implantation Is Associated With Contained Rupture of the Aortic Root

“…Although the clinical impact of untreated contained rupture is unknown, it appears conceivable that the occurrence of contained rupture as an assumed prestage to uncontained rupture should be avoided. Interestingly, in all 3 cases observed in the present study, as well as in the 2 cases described in literature so far, 13,15 contained rupture occurred adjacent to the left coronary sinus. This leads to the assumption that the tissue adjacent to the left coronary sinus represents a Locus minoris resistentiae.…”

“…8,13,15,24 In theory, both entities may belong to the spectrum of the same pathology, namely disruption of the aortoventricular junction, caused by either the forces of the preceding valvuloplasty or the actual TAVI procedure. In the study presented, we found 3 cases of contained rupture of the aortic root by means of MSCT.…”

“…[10][11][12] With the introduction of TAVI, performing physicians and surgeons may encounter incidents and complications different from those in conventional aortic valve surgery, such as annulus or aortic root rupture and pseudoaneurysm formation of the aortic root. 8,[13][14][15] These complications may be evident while performing the procedure or may be apparent at followup studies. However, data are limited and risk factors for these entities have not been investigated thoroughly yet.…”

Aortic aneurysm 18 month after transfemoral implantation of a self‐expandable aortic valve prosthesis

“…Only three cases have been published until today with confirmed aortic dissection as a cause of death following TAVI via the transapical and transfemoral route, respectively . In two cases (one transfemoral and one transapical), death occurred several days after the index procedure, whereas the third case was discovered as late as 1 year after transapical aortic valve implantation . In general, the observation of aneurysm formation after TAVI as seen in the present case highlights a new potential cause of unexplained death or clinical detoriation several days to months after TAVI.…”

Transcutaneous aortic valve implantation using the axillary/subclavian access with patent left internal thoracic artery to left anterior descending artery: Feasibility and early clinical outcomes

“…Moreover, a number of complications have been reported after the introduction of a percutaneous valve holder through the apex of the left ventricle. 9,10 In addition, although feasible, redo sternotomy in patients with patent grafts remains a risky procedure.…”