An approach to self-expandable dislocated valve to ascending Aorta
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An approach to self-expandable dislocated valve to ascending Aorta Sondos Samargandy and Abdulrahman Almoghairi
Introduction
This case illustrates the complexity of the Transcatheter Aortic Valve Replacement (TAVR) procedure, where rare complications are sometimes inescapable. Supra-annular dislocation of the self-expandable prosthesis was caused by attempting left main (LM) cannulation upon LM impairment after implantation of the TAVR valve, and treated successfully by retracting it towards the ascending Aorta and deploying another self-expandable valve. Then deploy a CP stent in between both of them.
Case presentation
A 79-year-old man with a history of diabetes mellitus, hypertension, bilateral osteoarthritis of the knees, and severe symptomatic Aortic stenosis (aortic valve area: 0.56 cm2, mean gradient: 53 mm hg), which caused exertional dyspnea (New York Heart Association functional class III/IV) over last six months.
Management decision
The heart team declined him for surgical AV replacement because of his advanced age and his history of multiple comorbidities classifying this as a -risk procedure. Thereafter, the structural interventional team decided on transfemoral TAVR and planned on using a 26-mm SEV prosthesis.
Interventional technique
Transfemoral TAVR was performed under fluoroscopic guidance and was uneventful until the actual valve deployment. After valve deployment, an ECG showed ST-segment elevation anteriorly, along with hypotension. Immediate EBU catheter 3.5 cannulations of the left main was attempted, but it dislocated the TAVR SEV to the ascending Aorta. We proceeded with PCI of the ostial LM with drug-eluting stent (5.0x12mm) flared up with same balloon. The patient started to be more stable at this stage so we proceeded with correcting the valve situation By snaring the dislodge valve & fixing it while delivering another SEV which was successfully placed in the aortic position. However, hemodynamically significant desynchrony appeared between the two valves, so we opted to use a stent of 25x29mm, optimizing both valves with immediate resolution of the desynchrony along patent great vessels. The bedside Echo showed no significant aortic regurgitation or paravalvular leak.
Discussion
Repositioning has been salutary for the self-expanding TAVR (SE-TAVR) (4). In the early days of the SEV snaring was the solely offered option for repositioning, or even for the positioning of the second prosthesis with highly predicted success. Nowadays, repositioning of the device uses around 30% for Evolut, 40% for Portico, and 60% for Lotus. (4-7). Repositioning maneuvers reveal anatomical challenges or technical complications such as AV block or para-valvular leak. In the earlier days, the majority of dislocated devices during TAVR implantations were intentionally a result of imperfect procedural results such as significant (paravalvular) regurgitation or impairment of the coronary ostia. Several case reports described accidental dislocations either infra-annular towards the left ventricle or supra-annular toward the ascending aorta. In our case, a second valve was deployed through the dislocated first device, and thereafter, for hemodynamic desynchrony, a stent was placed and well opposed to both devices. In such cases, either deploying a second device or placing a covered stent inside the migrated device. Implanting a covered stent will hamper the leaflet’s actions on the device. Hereafter, we decided to implant a covered stent to the dislocated valve by which the hemodynamic parameters were recovered smoothly. Furthermore, we presumed the traumatic risk associated with the migrated device was of great importance; since then, we have optimized the first device in position without any further manipulation with secured major vessel flow.
Conclusion
The TAVR procedure is a very well-matured technology that involves all categorical surgical risks. This case report, however, illustrates a rare complication that sometimes is inevitable. In this case, the complication of dislocation of the prosthesis was caused accidentally and dislocated proximally and managed successfully with a covered stent at the ascending Aorta and by deploying another prosthesis.