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Transcatheter aortic valve implantation in patient with cardiogenic shock
CRVASA-498; No. of Pages 3 cor et vasa xxx (2017) e1–e3
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.elsevier.com/locate/crvasa
Case report
Transcatheter aortic valve implantation in patient with cardiogenic shock Tadeas Butta *, Petr Hajek, Josef Veselka Department of Cardiology, Charles University in Prague, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
article info
abstract
Article history:
Transcatheter aortic valve implantation (TAVI) is an established treatment option in
Received 15 March 2017
patients with symptomatic severe aortic stenosis, who are at high or intermediate risk
Accepted 28 April 2017
for surgical aortic valve replacement. The vast majority of TAVI are performed on patients
Available online xxx
without acute decompensated heart failure. In this case report we present the successful TAVI in a patient with a cardiogenic shock.
Keywords:
© 2017 The Czech Society of Cardiology. Published by Elsevier Sp. z o.o. All rights reserved.
Aortic valve stenosis Transcatheter aortic valve implantation Acute decompensated heart failure Cardiogenic shock
Case report A 78-year-old woman was referred to our department for severe aortic stenosis symptomatic with exertional dyspnea (class III according to the New York Heart Association) and recurrent syncope. Echocardiography confirmed severe aortic stenosis with aortic valve area (AVA) 0.5 cm2 and mean pressure gradient (mean PG) 85 mmHg (Fig. 1A) with left ventricular ejection fraction of 60%. Coronary angiography and angiography of the aortic arch, aorta and iliac arteries showed no significant stenosis. Considering the high surgical risk and personal preferences, we decided to perform TAVI. The patient was discharged without signs of cardiac decompensation after the preoperative examinations, including computed
tomography (Fig. 1B), were completed. The TAVI procedure was scheduled in two weeks. In the evening on the day of the admission the patient suffered from syncope and a hemodynamic collapse, while she was walking to the bathroom. Physical examination revealed tachypnea (respiratory rate 50 min–1), signs of peripheral vasoconstriction and a Glasgow Coma Scale of 11. The patients blood pressure was 75/40 mmHg, the ECG monitor showed tachycardia of 110 beats per minute and echocardiography revealed left ventricular systolic dysfunction with ejection fraction of 30%. The patient was immediately transferred to coronary care unit. Arterial blood gas test showed lactate in excess of 7.0 mmol/l. The patient did not respond adequately to fluid resuscitation, therefore it was necessary to administer catecholamine support (norepinephrine at a dose of 0.9 mg/kg per minute, dobutamine at a dose 7 mg/kg per minute). We
* Corresponding author. E-mail address: [email protected] (T. Butta). http://dx.doi.org/10.1016/j.crvasa.2017.04.004 0010-8650/© 2017 The Czech Society of Cardiology. Published by Elsevier Sp. z o.o. All rights reserved.
Please cite this article in press as: T. Butta et al., Transcatheter aortic valve implantation in patient with cardiogenic shock, Cor et Vasa (2017), http://dx.doi.org/10.1016/j.crvasa.2017.04.004
CRVASA-498; No. of Pages 3
e2
cor et vasa xxx (2017) e1–e3
Fig. 2 – Final position of Lotus bioprothesis (25 mm).
successfully disconnected from the mechanical ventilation and since she remained hemodynamically stable, we were able to discontinue the catecholamine infusions. A control echocardiography study showed an optimal apposition of the aortic valve prosthesis with a small pressure gradient (mean PG 15 mmHg) and only a mild regurgitation. The patient was discharged two weeks after procedure and without a significant limitation by exertional dyspnea.
Discussion
Fig. 1 – (A) Transvalvular Doppler method with mean pressure gradient of 85 mmHg. (B) Computed tomography with size of aortic annulus.
performed a blood count and biochemistry analysis which did not explain the hemodynamic collapse (inflammatory markers, low hemoglobin concentration, etc.). Due to the concurrent respiratory failure it was also necessary to initiate mechanical ventilation (mode: PSIMV, FiO2: 50%, PEEP: 8 cmH2O, P insp.: 18 cmH2O, P supp. 18 cmH2O). Her diuresis was approximately 20 ml per hour at coronary care unit. The patient was transferred to catheterization laboratory, where a rescue TAVI procedure was performed (Fig. 2), 5 h after her hemodynamic collapse. The Lotus valve system (size 25 mm) was used via right femoral artery without balloon predilatation. Only 90 ml of contrast agent was applied during the procedure. Immediately after the valve implantation the systolic blood pressure increased from 80 mmHg to 140 mmHg, which allowed us to significantly reduce the vasopressor support. In the following days the patient was
Aortic stenosis is the most common valve disease in adults. Epidemiological studies show that more than one eight of patients over 75 years have moderate or severe aortic stenosis [1]. Patients with symptomatic severe aortic stenosis at high surgical risk, who are receiving only standard medical therapy have a one-year mortality of up to 50% and TAVI procedure significantly improves their chances of survival and their quality of life [2]. Since 2002 when the first TAVI was performed, the method gradually became a standard treatment in patients, who are contraindicated for surgical aortic valve replacement. It is currently considered also in patients with intermediate-risk of surgery. Unfortunatelly, some patients are admitted to the hospital at advanced stage of heart failure at a point when it is poorly pharmacologically suggestible. The patients usually require diuretics, which cause a decrease in the left ventricle preload and thus reduce the already decreased cardiac output. Urgent performed TAVI can interrupt this vicious circle. Some previously published studies suggest, that urgently performed TAVI procedures have comparable results to elective ones [3,4]. It is possible to bridge the period from the beginning of cardiogrenic shock to the TAVI procedure with mechanical cardiac support including intra-aortic ballon pump or extracorporeal membrane oxygenation (ECMO).
Please cite this article in press as: T. Butta et al., Transcatheter aortic valve implantation in patient with cardiogenic shock, Cor et Vasa (2017), http://dx.doi.org/10.1016/j.crvasa.2017.04.004
CRVASA-498; No. of Pages 3 cor et vasa xxx (2017) e1–e3
According to the literature, the use of mechanical cardiac support prior to a scheduled procedure decreases hospital mortality up to 25% in comparison with patients who require introduction of the support during the procedure [5]. Higher rate of early valve restenosis and poor long-term results of patients undergoing ballon aortic valvuloplasty (BAV) favorize TAVI procedure, but in specific circumstances BAV might be preferred, either as a final procedure in patients contraindicated for TAVI or as a bridging procedure (TAVI, noncardiac surgery) [6]. Our patient without prior heart failure history developed cardiogenic shock and only thanks to early bioprosthetic valve implantation her condition did not progress into multiple organ failure ultimately leading to the patient's death. We assume that every specialized department performing TAVI can encounter a patient, who requires an urgent TAVI. Therefore the time, between diagnosis and delivery of suitable bioprosthetic valve to perform TAVI, should be shortened as much as possible depending on the options of the department. We found after TAVI small pressure mean gradient (15 mmHg) in our patient and according to previously published studies is common and did not correlate with worse long time results [7].
Conclusions We present the successful implementation of TAVI in a patient with severe aortic stenosis with cardiogenic shock, which is a rare form of presentation of decompensated heart failure in patients with aortic stenosis undergoing TAVI. The implantation of the TAVI prosthesis lead to an immediate improvement in the patients hemodynamic state.
Conflict of interest The authors have no conflicts of interest to disclose.
Ethical statement
e3
Informed consent The authors declare that informed consent with this case report was obtained from the patient.
Funding body None.
references
[1] V.T. Nkomo, J.M. Gardin, T.N. Skelton, et al., Burden of valvular heart diseases: a population-based study, Lancet 368 (2006) 1005–1011. [2] M.B. Leon, C.R. Smith, M. Mack, et al., Transcatheter aorticvalve implantation for aortic stenosis in patients who cannot undergo surgery, The New England Journal of Medicine 363 (2010) 1597–1607. [3] S. Alnasser, M.D. Peterson, S.S. Sharma, A. Cheema, TCT-690 safety and efficacy of urgent transcatheter aortic valve replacement in patients admitted with decompensated heart failure, Journal of the American College of Cardiology 64 (11) (2014) B202. [4] U. Landes, K. Orvin, P. Codner, et al., Urgent transcatheter aortic valve implantation in patients with severe aortic stenosis and acute heart failure: procedural and 30-day outcomes, Canadian Journal of Cardiology 326 (2016) 726–731. [5] V. Singh, A.A. Damluji, R. Mendirichaga, et al., Elective or emergency use of mechanical circulatory support devices during transcatheter aortic valve replacement, Journal of Interventional Cardiology 29 (October (5)) (2016) 513–522. [6] C. Tron, A. Bizios, E. Durand, et al., Emergency percutaneous valvuloplasty: which patients, which results? La Presse Médicale 45 (October (10)) (2016) 898–902. [7] M.B. Leon, C.R. Smith, M.J. Mack, et al., Transcatheter or surgical aortic-valve replacement in intermediate-risk patients, The New England Journal of Medicine 374 (April (17)) (2016) 1609–1620.
Authors state that the research was conducted according to ethical standards.
Please cite this article in press as: T. Butta et al., Transcatheter aortic valve implantation in patient with cardiogenic shock, Cor et Vasa (2017), http://dx.doi.org/10.1016/j.crvasa.2017.04.004
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.elsevier.com/locate/crvasa
Case report
Transcatheter aortic valve implantation in patient with cardiogenic shock Tadeas Butta *, Petr Hajek, Josef Veselka Department of Cardiology, Charles University in Prague, 2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic
article info
abstract
Article history:
Transcatheter aortic valve implantation (TAVI) is an established treatment option in
Received 15 March 2017
patients with symptomatic severe aortic stenosis, who are at high or intermediate risk
Accepted 28 April 2017
for surgical aortic valve replacement. The vast majority of TAVI are performed on patients
Available online xxx
without acute decompensated heart failure. In this case report we present the successful TAVI in a patient with a cardiogenic shock.
Keywords:
© 2017 The Czech Society of Cardiology. Published by Elsevier Sp. z o.o. All rights reserved.
Aortic valve stenosis Transcatheter aortic valve implantation Acute decompensated heart failure Cardiogenic shock
Case report A 78-year-old woman was referred to our department for severe aortic stenosis symptomatic with exertional dyspnea (class III according to the New York Heart Association) and recurrent syncope. Echocardiography confirmed severe aortic stenosis with aortic valve area (AVA) 0.5 cm2 and mean pressure gradient (mean PG) 85 mmHg (Fig. 1A) with left ventricular ejection fraction of 60%. Coronary angiography and angiography of the aortic arch, aorta and iliac arteries showed no significant stenosis. Considering the high surgical risk and personal preferences, we decided to perform TAVI. The patient was discharged without signs of cardiac decompensation after the preoperative examinations, including computed
tomography (Fig. 1B), were completed. The TAVI procedure was scheduled in two weeks. In the evening on the day of the admission the patient suffered from syncope and a hemodynamic collapse, while she was walking to the bathroom. Physical examination revealed tachypnea (respiratory rate 50 min–1), signs of peripheral vasoconstriction and a Glasgow Coma Scale of 11. The patients blood pressure was 75/40 mmHg, the ECG monitor showed tachycardia of 110 beats per minute and echocardiography revealed left ventricular systolic dysfunction with ejection fraction of 30%. The patient was immediately transferred to coronary care unit. Arterial blood gas test showed lactate in excess of 7.0 mmol/l. The patient did not respond adequately to fluid resuscitation, therefore it was necessary to administer catecholamine support (norepinephrine at a dose of 0.9 mg/kg per minute, dobutamine at a dose 7 mg/kg per minute). We
* Corresponding author. E-mail address: [email protected] (T. Butta). http://dx.doi.org/10.1016/j.crvasa.2017.04.004 0010-8650/© 2017 The Czech Society of Cardiology. Published by Elsevier Sp. z o.o. All rights reserved.
Please cite this article in press as: T. Butta et al., Transcatheter aortic valve implantation in patient with cardiogenic shock, Cor et Vasa (2017), http://dx.doi.org/10.1016/j.crvasa.2017.04.004
CRVASA-498; No. of Pages 3
e2
cor et vasa xxx (2017) e1–e3
Fig. 2 – Final position of Lotus bioprothesis (25 mm).
successfully disconnected from the mechanical ventilation and since she remained hemodynamically stable, we were able to discontinue the catecholamine infusions. A control echocardiography study showed an optimal apposition of the aortic valve prosthesis with a small pressure gradient (mean PG 15 mmHg) and only a mild regurgitation. The patient was discharged two weeks after procedure and without a significant limitation by exertional dyspnea.
Discussion
Fig. 1 – (A) Transvalvular Doppler method with mean pressure gradient of 85 mmHg. (B) Computed tomography with size of aortic annulus.
performed a blood count and biochemistry analysis which did not explain the hemodynamic collapse (inflammatory markers, low hemoglobin concentration, etc.). Due to the concurrent respiratory failure it was also necessary to initiate mechanical ventilation (mode: PSIMV, FiO2: 50%, PEEP: 8 cmH2O, P insp.: 18 cmH2O, P supp. 18 cmH2O). Her diuresis was approximately 20 ml per hour at coronary care unit. The patient was transferred to catheterization laboratory, where a rescue TAVI procedure was performed (Fig. 2), 5 h after her hemodynamic collapse. The Lotus valve system (size 25 mm) was used via right femoral artery without balloon predilatation. Only 90 ml of contrast agent was applied during the procedure. Immediately after the valve implantation the systolic blood pressure increased from 80 mmHg to 140 mmHg, which allowed us to significantly reduce the vasopressor support. In the following days the patient was
Aortic stenosis is the most common valve disease in adults. Epidemiological studies show that more than one eight of patients over 75 years have moderate or severe aortic stenosis [1]. Patients with symptomatic severe aortic stenosis at high surgical risk, who are receiving only standard medical therapy have a one-year mortality of up to 50% and TAVI procedure significantly improves their chances of survival and their quality of life [2]. Since 2002 when the first TAVI was performed, the method gradually became a standard treatment in patients, who are contraindicated for surgical aortic valve replacement. It is currently considered also in patients with intermediate-risk of surgery. Unfortunatelly, some patients are admitted to the hospital at advanced stage of heart failure at a point when it is poorly pharmacologically suggestible. The patients usually require diuretics, which cause a decrease in the left ventricle preload and thus reduce the already decreased cardiac output. Urgent performed TAVI can interrupt this vicious circle. Some previously published studies suggest, that urgently performed TAVI procedures have comparable results to elective ones [3,4]. It is possible to bridge the period from the beginning of cardiogrenic shock to the TAVI procedure with mechanical cardiac support including intra-aortic ballon pump or extracorporeal membrane oxygenation (ECMO).
Please cite this article in press as: T. Butta et al., Transcatheter aortic valve implantation in patient with cardiogenic shock, Cor et Vasa (2017), http://dx.doi.org/10.1016/j.crvasa.2017.04.004
CRVASA-498; No. of Pages 3 cor et vasa xxx (2017) e1–e3
According to the literature, the use of mechanical cardiac support prior to a scheduled procedure decreases hospital mortality up to 25% in comparison with patients who require introduction of the support during the procedure [5]. Higher rate of early valve restenosis and poor long-term results of patients undergoing ballon aortic valvuloplasty (BAV) favorize TAVI procedure, but in specific circumstances BAV might be preferred, either as a final procedure in patients contraindicated for TAVI or as a bridging procedure (TAVI, noncardiac surgery) [6]. Our patient without prior heart failure history developed cardiogenic shock and only thanks to early bioprosthetic valve implantation her condition did not progress into multiple organ failure ultimately leading to the patient's death. We assume that every specialized department performing TAVI can encounter a patient, who requires an urgent TAVI. Therefore the time, between diagnosis and delivery of suitable bioprosthetic valve to perform TAVI, should be shortened as much as possible depending on the options of the department. We found after TAVI small pressure mean gradient (15 mmHg) in our patient and according to previously published studies is common and did not correlate with worse long time results [7].
Conclusions We present the successful implementation of TAVI in a patient with severe aortic stenosis with cardiogenic shock, which is a rare form of presentation of decompensated heart failure in patients with aortic stenosis undergoing TAVI. The implantation of the TAVI prosthesis lead to an immediate improvement in the patients hemodynamic state.
Conflict of interest The authors have no conflicts of interest to disclose.
Ethical statement
e3
Informed consent The authors declare that informed consent with this case report was obtained from the patient.
Funding body None.
references
[1] V.T. Nkomo, J.M. Gardin, T.N. Skelton, et al., Burden of valvular heart diseases: a population-based study, Lancet 368 (2006) 1005–1011. [2] M.B. Leon, C.R. Smith, M. Mack, et al., Transcatheter aorticvalve implantation for aortic stenosis in patients who cannot undergo surgery, The New England Journal of Medicine 363 (2010) 1597–1607. [3] S. Alnasser, M.D. Peterson, S.S. Sharma, A. Cheema, TCT-690 safety and efficacy of urgent transcatheter aortic valve replacement in patients admitted with decompensated heart failure, Journal of the American College of Cardiology 64 (11) (2014) B202. [4] U. Landes, K. Orvin, P. Codner, et al., Urgent transcatheter aortic valve implantation in patients with severe aortic stenosis and acute heart failure: procedural and 30-day outcomes, Canadian Journal of Cardiology 326 (2016) 726–731. [5] V. Singh, A.A. Damluji, R. Mendirichaga, et al., Elective or emergency use of mechanical circulatory support devices during transcatheter aortic valve replacement, Journal of Interventional Cardiology 29 (October (5)) (2016) 513–522. [6] C. Tron, A. Bizios, E. Durand, et al., Emergency percutaneous valvuloplasty: which patients, which results? La Presse Médicale 45 (October (10)) (2016) 898–902. [7] M.B. Leon, C.R. Smith, M.J. Mack, et al., Transcatheter or surgical aortic-valve replacement in intermediate-risk patients, The New England Journal of Medicine 374 (April (17)) (2016) 1609–1620.
Authors state that the research was conducted according to ethical standards.
Please cite this article in press as: T. Butta et al., Transcatheter aortic valve implantation in patient with cardiogenic shock, Cor et Vasa (2017), http://dx.doi.org/10.1016/j.crvasa.2017.04.004