- Email: [email protected]
Extrinsic compression of the left main coronary artery by a contained aortic annular rupture following trans-catheter aortic valve implantation
Cardiovascular Revascularization Medicine 16 (2015) 313–316
Contents lists available at ScienceDirect
Cardiovascular Revascularization Medicine
Extrinsic compression of the left main coronary artery by a contained aortic annular rupture following trans-catheter aortic valve implantation☆,☆☆ Aharon Erez, Israel Barbash, Dan Spiegelstein, Alexander Kogan, Ashraf Hamdan, Amichai Shinfeld, Sergey Preisman, Amit Segev ⁎ The Heart Center, Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
a r t i c l e
i n f o
Article history: Received 18 March 2015 Received in revised form 11 May 2015 Accepted 14 May 2015 Keywords: TAVR Annular rupture PCI Complication
a b s t r a c t We present a case of an 83-year-old female who suffered from annular rupture with contained hematoma immediately after trans-apical implantation of balloon-expandable Sapien valve. The patient developed acute cardiogenic shock which resulted from an extrinsic compression of the left main coronary artery. We report the successful management of this complication. © 2015 Elsevier Inc. All rights reserved.
1. Introduction Trans-catheter aortic valve implantation (TAVI) is widely recognized as an alternate therapy for patients with severe aortic stenosis and high surgical risk for conventional surgical valve replacement. However, this procedure has inherent risks that physicians must recognize and understand. Rupture of the device landing zone, albeit rare, is one of the most lethal complications. We describe the case of an acute hemodynamic collapse after a contained rupture and a successful percutaneous treatment of this complication. 2. Case presentation An 82-year-old woman with symptomatic severe aortic stenosis, logistic EuroSCORE I (European System for Cardiac Operative Risk Evaluation) of 19.6%, EuroSCORE II of 2.27%, and Society of Thoracic Surgeons' (STS) estimated surgical mortality of 3.12%, underwent TAVI. Trans-thoracic echocardiogram (TTE) showed a heavily calcified aortic valve with peak aortic gradient of 60 mmHg, ean gradient of 40 mmHg, Vmax of 388 cm/sec, calculated aortic valve area of 0.5 cm 2, and good left ventricular systolic function. Computed
☆ Disclosures: Amit Segev is a proctor for Edwards Lifesciences and Medtronic Inc. ☆☆ Funding: None. ⁎ Corresponding author at: Interventional Cardiology Unit, Chaim Sheba Medical Center, Tel Hashomer, Israel. Tel.: +972 52 6667581; fax: +972 3 5305789. E-mail address: [email protected] (A. Segev). http://dx.doi.org/10.1016/j.carrev.2015.05.005 1553-8389/© 2015 Elsevier Inc. All rights reserved.
tomographic angiography (CTA) demonstrated heavily calcified aortic root, leaflets, and annulus (Fig. 1). Annulus' diameters were 18 mm by 26.6 mm, perimeter was 63 mm, and average diameter was 22.1 mm. CTA also showed small (b 5 mm) ileo-femoral arteries not suitable for trans-femoral access. Therefore, the decision of "heart team" was to refer her to trans-apical implantation of a 23 mm Edwards-Sapien XT (Edwards Lifesciences, Irvine, CA, USA) valve. Pre-dilation was performed using a 20 mm balloon, and the valve was implanted successfully in a 50–50 position. However, the immediate post-deployment aortogram showed leakage of die outside the left sinus (Fig. 2). There was no evidence of cardiac tamponade, hence the hematoma was contained around the aortic root. Despite that fact, the patient developed immediate hemodynamic collapse. QRS widening and ST-elevation on monitor leads were noticed. Angiographic images showed that the left main coronary artery (LMCA) is narrowed and collapsed with reduced TIMI flow (Fig. 2). Trans-esophageal echocardiogram that was used throughout the procedure confirmed the presence of a contained hematoma compressing the left main coronary artery (Fig. 3). An emergent percutaneous intervention was performed within minutes from collapse a deployment of two drug-eluting stents from LMCA into LAD and from LMCA into left circumflex artery using the cullotte technique with final kissing-balloon dilatation (Fig. 4). After the restoration of coronary flow, the patient had been stabilized, chest was closed, and she was admitted to the cardio-thoracic intensive care unit. Patient remained stable, and serial CTAs showed a stable false aneurysm without further expansion. She was discharged to a rehabilitation facility on day 14 post-procedure.
314
A. Erez et al. / Cardiovascular Revascularization Medicine 16 (2015) 313–316
Fig. 1. Preoperative multidetector computed tomography assessment showing calcified aortic valve, sub-annular calcification, and calcified annulus.
At 6 month follow-up, patient is stable at New York Heart Association functional class I. Echocardiography showed wellfunctioning valve with acceptable residual gradient and mild to moderate para-valvular leak. Fig. 5 shows CTA images at 6 months showing patent coronary stents and small, contained false aneurysm of the left coronary sinus.
Fig. 2. Angiography showing extrinsic compression of the left coronary arteries (upper arrow) by contained aortic annulus rupture (lower arrow).
3. Discussion We report herein a case of hemodynamic collapse immediately after trans-apical TAVI using a balloon-expanding valve resulting from an extrinsic compression of the left main coronary artery by a contained annular rupture. Due to early identification, and immediate stent implantation in the left main coronary artery, patient was successfully treated and had uneventful hospital stay until discharge. Annular rupture is a catastrophic and usually fatal complication after TAVI that occurs in 0.1% to 1% of the patients undergoing this procedure [1]. Mortality rate after annular rupture is approximately 50% [2]. The most commonly recognized presentation is acute tamponade or massive intra-thoracic bleeding, which are usually immediately fatal unless emergent surgery is performed. Ruptures have been more frequently reported with the use of balloon-expandable relative to self-expanding transcatheter heart valves. A contained rupture of the aortic root in balloon-expandable TAVI is associated with prosthesis oversizing [3] as well as other predisposing factors such as heavy calcification [4,5]. In our case sizing was correct, however native valve was severely calcified with calcifications extended beyond the annulus to the aorto-mitral continuity as clearly shown by the CTA. While free aortic root rupture and peri-aortic hematoma may belong to the same spectrum of the same pathology, peri-aortic hematoma usually has a more favorable prognosis. In cases of trans-aortic approach where the sternum is open, a contained rupture is usually visualized and can be managed with a conservative wait-and-watch policy [6,7]. Hemodynamic compromise following a contained annulus rupture without evidence of cardiac tamponade or overt bleeding, should lead to search for a different direct cause of the hemodynamic collapse. In the case presented, we immediately identified that collapse was not caused directly by the rupture and/or bleeding, but via the extrinsic compression on the
A. Erez et al. / Cardiovascular Revascularization Medicine 16 (2015) 313–316
315
Fig. 3. Intra-procedural trans-esophageal images of the hematoma (left panel), and left main coronary artery compressed by the peri-aortic hematoma (right panel).
In conclusion, although a rare complication, an extrinsic compression of the coronary arteries needs to be considered in patients who develop shock following TAVI. This complication can be overlooked when detecting an annular rupture. However a correct diagnosis of this complication can lead to a successful percutaneous treatment, as presented in this case. References
Fig. 4. Final result of successful cullotte bifurcation stenting of left main coronary artery into LAD and left circumflex arteries.
left main coronary artery compromising coronary flow. This had led to a successful percutaneous management of this complication.
[1] Hayashida K, Bouvier E, Lefevre T, et al. Potential mechanism of annulus rupture during transcatheter aortic valve implantation. Catheter Cardiovasc Interv 2013;82: E742–6. [2] Barbanti M, Yang TH, Rodes Cabau J, et al. Anatomical and procedural features associated with aortic root rupture during balloon-expandable transcatheter aortic valve replacement. Circulation 2013;128:244–53. [3] Blanke P, Reinohl J, Schlensak C, et al. Prosthesis oversizing in balloon-expandable transcatheter aortic valve implantation is associated with contained rupture of the aortic root. Circ Cardiovasc Interv 2012;5:540–8. [4] Schymik G, Heimeshoff M, Bramlage P, et al. Ruptures of the device landing zone in patients undergoing transcatheter aortic valve implantation: an analysis of TAVI Karlsruhe (TAVIK) patients. Clin Res Cardiol 2014;103:912–20. [5] Masson JB, Kovac J, Schuler G, et al. Transcatheter aortic valve implantation: review of the nature, management, and avoidance of procedural complications. JACC Cardiovasc Interv 2009;2:811–20. [6] Genereux P, Reiss GR, Kodali SK, et al. Periaortic hematoma after transcatheter aortic valve replacement: description of a new complication. Catheter Cardiovasc Interv 2012;79:766–76. [7] Stortecky S, Buellesfeld L, Wenaweser P, et al. Transcatheter aortic valve implantation: prevention and management of complications. Heart 2012;98(Suppl. 4): iv52–64.
316
A. Erez et al. / Cardiovascular Revascularization Medicine 16 (2015) 313–316
Fig. 5. Six-month follow-up CTA images showing small residual hematoma (arrows) and patent coronary stents.
Contents lists available at ScienceDirect
Cardiovascular Revascularization Medicine
Extrinsic compression of the left main coronary artery by a contained aortic annular rupture following trans-catheter aortic valve implantation☆,☆☆ Aharon Erez, Israel Barbash, Dan Spiegelstein, Alexander Kogan, Ashraf Hamdan, Amichai Shinfeld, Sergey Preisman, Amit Segev ⁎ The Heart Center, Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
a r t i c l e
i n f o
Article history: Received 18 March 2015 Received in revised form 11 May 2015 Accepted 14 May 2015 Keywords: TAVR Annular rupture PCI Complication
a b s t r a c t We present a case of an 83-year-old female who suffered from annular rupture with contained hematoma immediately after trans-apical implantation of balloon-expandable Sapien valve. The patient developed acute cardiogenic shock which resulted from an extrinsic compression of the left main coronary artery. We report the successful management of this complication. © 2015 Elsevier Inc. All rights reserved.
1. Introduction Trans-catheter aortic valve implantation (TAVI) is widely recognized as an alternate therapy for patients with severe aortic stenosis and high surgical risk for conventional surgical valve replacement. However, this procedure has inherent risks that physicians must recognize and understand. Rupture of the device landing zone, albeit rare, is one of the most lethal complications. We describe the case of an acute hemodynamic collapse after a contained rupture and a successful percutaneous treatment of this complication. 2. Case presentation An 82-year-old woman with symptomatic severe aortic stenosis, logistic EuroSCORE I (European System for Cardiac Operative Risk Evaluation) of 19.6%, EuroSCORE II of 2.27%, and Society of Thoracic Surgeons' (STS) estimated surgical mortality of 3.12%, underwent TAVI. Trans-thoracic echocardiogram (TTE) showed a heavily calcified aortic valve with peak aortic gradient of 60 mmHg, ean gradient of 40 mmHg, Vmax of 388 cm/sec, calculated aortic valve area of 0.5 cm 2, and good left ventricular systolic function. Computed
☆ Disclosures: Amit Segev is a proctor for Edwards Lifesciences and Medtronic Inc. ☆☆ Funding: None. ⁎ Corresponding author at: Interventional Cardiology Unit, Chaim Sheba Medical Center, Tel Hashomer, Israel. Tel.: +972 52 6667581; fax: +972 3 5305789. E-mail address: [email protected] (A. Segev). http://dx.doi.org/10.1016/j.carrev.2015.05.005 1553-8389/© 2015 Elsevier Inc. All rights reserved.
tomographic angiography (CTA) demonstrated heavily calcified aortic root, leaflets, and annulus (Fig. 1). Annulus' diameters were 18 mm by 26.6 mm, perimeter was 63 mm, and average diameter was 22.1 mm. CTA also showed small (b 5 mm) ileo-femoral arteries not suitable for trans-femoral access. Therefore, the decision of "heart team" was to refer her to trans-apical implantation of a 23 mm Edwards-Sapien XT (Edwards Lifesciences, Irvine, CA, USA) valve. Pre-dilation was performed using a 20 mm balloon, and the valve was implanted successfully in a 50–50 position. However, the immediate post-deployment aortogram showed leakage of die outside the left sinus (Fig. 2). There was no evidence of cardiac tamponade, hence the hematoma was contained around the aortic root. Despite that fact, the patient developed immediate hemodynamic collapse. QRS widening and ST-elevation on monitor leads were noticed. Angiographic images showed that the left main coronary artery (LMCA) is narrowed and collapsed with reduced TIMI flow (Fig. 2). Trans-esophageal echocardiogram that was used throughout the procedure confirmed the presence of a contained hematoma compressing the left main coronary artery (Fig. 3). An emergent percutaneous intervention was performed within minutes from collapse a deployment of two drug-eluting stents from LMCA into LAD and from LMCA into left circumflex artery using the cullotte technique with final kissing-balloon dilatation (Fig. 4). After the restoration of coronary flow, the patient had been stabilized, chest was closed, and she was admitted to the cardio-thoracic intensive care unit. Patient remained stable, and serial CTAs showed a stable false aneurysm without further expansion. She was discharged to a rehabilitation facility on day 14 post-procedure.
314
A. Erez et al. / Cardiovascular Revascularization Medicine 16 (2015) 313–316
Fig. 1. Preoperative multidetector computed tomography assessment showing calcified aortic valve, sub-annular calcification, and calcified annulus.
At 6 month follow-up, patient is stable at New York Heart Association functional class I. Echocardiography showed wellfunctioning valve with acceptable residual gradient and mild to moderate para-valvular leak. Fig. 5 shows CTA images at 6 months showing patent coronary stents and small, contained false aneurysm of the left coronary sinus.
Fig. 2. Angiography showing extrinsic compression of the left coronary arteries (upper arrow) by contained aortic annulus rupture (lower arrow).
3. Discussion We report herein a case of hemodynamic collapse immediately after trans-apical TAVI using a balloon-expanding valve resulting from an extrinsic compression of the left main coronary artery by a contained annular rupture. Due to early identification, and immediate stent implantation in the left main coronary artery, patient was successfully treated and had uneventful hospital stay until discharge. Annular rupture is a catastrophic and usually fatal complication after TAVI that occurs in 0.1% to 1% of the patients undergoing this procedure [1]. Mortality rate after annular rupture is approximately 50% [2]. The most commonly recognized presentation is acute tamponade or massive intra-thoracic bleeding, which are usually immediately fatal unless emergent surgery is performed. Ruptures have been more frequently reported with the use of balloon-expandable relative to self-expanding transcatheter heart valves. A contained rupture of the aortic root in balloon-expandable TAVI is associated with prosthesis oversizing [3] as well as other predisposing factors such as heavy calcification [4,5]. In our case sizing was correct, however native valve was severely calcified with calcifications extended beyond the annulus to the aorto-mitral continuity as clearly shown by the CTA. While free aortic root rupture and peri-aortic hematoma may belong to the same spectrum of the same pathology, peri-aortic hematoma usually has a more favorable prognosis. In cases of trans-aortic approach where the sternum is open, a contained rupture is usually visualized and can be managed with a conservative wait-and-watch policy [6,7]. Hemodynamic compromise following a contained annulus rupture without evidence of cardiac tamponade or overt bleeding, should lead to search for a different direct cause of the hemodynamic collapse. In the case presented, we immediately identified that collapse was not caused directly by the rupture and/or bleeding, but via the extrinsic compression on the
A. Erez et al. / Cardiovascular Revascularization Medicine 16 (2015) 313–316
315
Fig. 3. Intra-procedural trans-esophageal images of the hematoma (left panel), and left main coronary artery compressed by the peri-aortic hematoma (right panel).
In conclusion, although a rare complication, an extrinsic compression of the coronary arteries needs to be considered in patients who develop shock following TAVI. This complication can be overlooked when detecting an annular rupture. However a correct diagnosis of this complication can lead to a successful percutaneous treatment, as presented in this case. References
Fig. 4. Final result of successful cullotte bifurcation stenting of left main coronary artery into LAD and left circumflex arteries.
left main coronary artery compromising coronary flow. This had led to a successful percutaneous management of this complication.
[1] Hayashida K, Bouvier E, Lefevre T, et al. Potential mechanism of annulus rupture during transcatheter aortic valve implantation. Catheter Cardiovasc Interv 2013;82: E742–6. [2] Barbanti M, Yang TH, Rodes Cabau J, et al. Anatomical and procedural features associated with aortic root rupture during balloon-expandable transcatheter aortic valve replacement. Circulation 2013;128:244–53. [3] Blanke P, Reinohl J, Schlensak C, et al. Prosthesis oversizing in balloon-expandable transcatheter aortic valve implantation is associated with contained rupture of the aortic root. Circ Cardiovasc Interv 2012;5:540–8. [4] Schymik G, Heimeshoff M, Bramlage P, et al. Ruptures of the device landing zone in patients undergoing transcatheter aortic valve implantation: an analysis of TAVI Karlsruhe (TAVIK) patients. Clin Res Cardiol 2014;103:912–20. [5] Masson JB, Kovac J, Schuler G, et al. Transcatheter aortic valve implantation: review of the nature, management, and avoidance of procedural complications. JACC Cardiovasc Interv 2009;2:811–20. [6] Genereux P, Reiss GR, Kodali SK, et al. Periaortic hematoma after transcatheter aortic valve replacement: description of a new complication. Catheter Cardiovasc Interv 2012;79:766–76. [7] Stortecky S, Buellesfeld L, Wenaweser P, et al. Transcatheter aortic valve implantation: prevention and management of complications. Heart 2012;98(Suppl. 4): iv52–64.
316
A. Erez et al. / Cardiovascular Revascularization Medicine 16 (2015) 313–316
Fig. 5. Six-month follow-up CTA images showing small residual hematoma (arrows) and patent coronary stents.