Clinical Images

Can Lightning Strike Twice? Tackling Complications From Transcatheter Aortic Valve Implantation

Jonathan Yap, MBBS, MRCP, MPH1;  See Hooi Ewe, MBBS, MRCP, PhD1;  Victor Chao, MBBS, FRCS2;  Kay Woon Ho, MBBS, MRCP1

Jonathan Yap, MBBS, MRCP, MPH1;  See Hooi Ewe, MBBS, MRCP, PhD1;  Victor Chao, MBBS, FRCS2;  Kay Woon Ho, MBBS, MRCP1

J INVASIVE CARDIOL 2019;31(9):E277.

Key words: cardiac imaging, complications, computed tomography, TAVI, transesophageal echocardiography

A 79-year-old female with known severe degenerative calcified aortic stenosis underwent transfemoral transcatheter aortic valve implantation (TAVI) with a 25 mm Portico valve (Abbott Vascular) under local anesthesia with micro-transesophageal echocardiographic (TEE) guidance. At the end of the procedure, prior to groin closure, the patient was hypotensive. Aortogram showed patent coronaries and no aortic dissection/annular rupture. Micro-TEE showed normal aortic valve (AV) gradients with mild paravalvular aortic regurgitation, but a new pericardial effusion. Pericardiocentesis was performed and 700 mL of blood were withdrawn. Left ventriculogram confirmed a left ventricle (LV) perforation (Figure 1A; Video 1) suspected to arise from manipulation of the Confida wire (Medtronic). A median sternotomy was performed and a focal perforation from the lateral LV wall was repaired with direct sutures (Figure 1B; Video 1). On postoperative day 4, transthoracic echocardiogram (TTE) showed no residual pericardial effusion but new turbulent flow across the AV (maximum velocity, 4 m/s). Three-dimensional TEE showed restricted opening of the non-coronary cusp (NCC) leaflet (Figure 1C; Video 1). The diagnosis of prosthetic valve thrombosis was confirmed with computed tomography (CT) aortogram, which showed thrombus on the immobile NCC leaflet (Figures 1D and 1E; Video 1). Anticoagulation was started. After 6 weeks of anticoagulation, repeat TTE showed normal AV gradients and repeat CT aortogram showed resolution of the NCC thrombus. TAVI complications may occur in the peri- and postprocedural periods. The physician needs to be aware of the differentials for such complications and well versed in their attendant management.

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From the Departments of 1Cardiology and 2Cardiothoracic Surgery, National Heart Centre Singapore, Singapore.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted January 22, 2019.

Address for correspondence: Dr Kay Woon Ho, National Heart Centre Singapore, 5 Hospital Drive, Singapore 169609. Email: