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Immediate aortic embolization of a balloon expandable valve during transfemoral TAVI in a patient with borderline-sized annulus

Carla Agatiello, MD TAVI Program Coordinator Interventional Cardiology Hospital Italiano de Bs As carla.agatiello@hospitalitaliano.org.ar


Potencial conflictos de interés Nombre: Carla AGATIELLO

❑ Proctor ACURATE TA(Boston Scientific/Symetis)


Clinical Background 82 year old, female Weight 60 kg, Height 1.48 m Frailty Hipertension Diabetes type II Atrial Fibrillation under anticoagulation EKG: RBB Aortic stenosis symptomatic NYHA class III


Coronary angiogram


ETT


Anatomical considerations

Sinotubular Junction Diameters: 27.5 x 27.6 mm

Aortic Sinus

Annulus Diameters: 24 x 20 mm Area: 412 mm2

Acceso minimo para 18Fr Sin disponer de dispositivos 14FR Calcio en compas aorto-iliaco


ANILLO AORTICO y ostiums coronarios

• •

Altura a los ostiums coronarios Forma de anillo, perímetro y área para seleccionar la bioprótesis adecuada


TAVI TF Prรณtesis SAPIEN XT#23-26


BAV preTAVI Procedure

Right femoral access (16F) by cut down Sapien XT 23 mm(Area:412mm2) Predilation 20x40mm, with 16ml


TAVI Procedure


TAVI Procedure: Migration

Too slow TAVI inflation Too slow pigtail removal Pacing 180 TA 40mmHg No ESV


TAVI removal

Balloon-assisted pull-back maneuver and inflation in the aortic arch


TAVI removal

Inflation in the aortic arch and angiographic control of left subclavia


TAVI removal Balloon-assisted pull-back maneuver and inflation in the aortic arch


TAVI TA

No paravalular leak • MG 6 mmHg • Atriventricular block and PM implanted • Discharged day 6


Take Home Messages Transcatheter heart valve embolization is a rare but serious complication with elevated morbidity and mortality The most common reason of the aortic embolization is the malpositioning of the valve (especially when too aortic).

Other reasons include: incorrect size of the annulus, wrong selection of valve size, inadecuate ventricular pacing, lack of native valve calcification among others. Valve-in-valve is a good option when possible, however, retraction of the embolized valve with balloon into de descending aorta is another viable option


Rouen 1994: Autopsy findings PostStent RC A

L M

Heigt h 17m m IV Septum

EU Patent

Mitral


Tips to avoid balloon expandable valve migration Correct sizing valve Correct initial TAVI position (not too low, not too aortic) Relief tension of the system Adequate rapid pacing with systolic collapse Coordination between 1st and 2nd operator during inflation Carefully remove pigtail before start TAVI deployment


Anupama Shivaraju et al. JCIN 2015;8:2041-2043


Anupama Shivaraju et al. JCIN 2015;8:2041-2043


Case #2 Ad-hoc left main protection and valve size selection for TAVI after pre-implantation valvuloplasty SEROPIAN I.1, FALCONI M2., FERNANDEZ A., BIANCO J.3, OBERTI P.2, KOTOWICZ V.4, AGATIELLO C1., BERROCAL D. 1 1Interventional

Cardiology Department. – 2Cardiac Surgery Department. – 3Anesthesiology Deparment – 4Cardiovascular Imaging Section, Cardiology Department. Hospital Italiano de Buenos Aires. Argentina


CASE PRESENTATION 88 years old female patient with severe aortic stenosis, NYHA I with preserved ejection fraction. • Cardiovascular Risk Factors: Hypertension, hyperlipidemia • Cardiovascular History: Paroxysmal atrial fibrillation, anticoagulated (coumadin)

• Heart Team decision: TAVI due to frailty (Edmonton 8/17, Fried 4/5) and risk of fall (history of several falls). •STS Score: 3.29%

• Euroscore II: 1.38%


PRE-TAVI STUDIES

ECG: Normal sinus rhythm, narrow QRS Echo: Max Grad. 73 mmHg, Mean Grad. 44 mmHg, valve area 0.6 cm2/m2, EF 65%, mild aortic regurgitation

Coronary Angiography: Nonobstructive coronary artery disease. Right radial access (6Fr). Patient presented vasoespasm.


CONTRAST-CT (Heart Team Measurements)

Valve to left main height: 10.5 mm Leaflet lenght: 18 mm

Valve to right coronary artery: 11.9 mm Leaflet lenght: 19 mm


CONTRAST-CT (Valve Manufacturer Measurments) Summary - 23 mm balloon expandable valve. -Right femoral approach - No strong recommendation on left main protection.

Valve to left main height

Valve to right coronary artery height


PRE-IMPLANTATION VALVULOPLASTY Root aortogram (perpendicular view)

Balloon aortic valvuloplasty (20x40 mm)

Balloon aortic valvuloplasty (20x40 mm)

Patent left main during valvuloplasty but: 1) Severely reduced left sinus space. CATH-LAB HEART 2) Leaflet extending above left main origin (‘white line sign’) TEAM DISCUSSION 3) No aortic regurgitation through left coronary sinus

• PROTECT LEFT MAIN • 23 mm SIZE VALVE


AD-HOC LEFT MAIN PROTECTION ACCESSS SUMMARY: - Right Radial Artery: Absence of pulse (previos coronary angiograhy). - Left Radial Artery: Arterial line – 20G (anesthesiology). - Right Femoral Artery: Surgical dissection - 18Fr e-Sheath. - Left Femoral Artery: Pig Tail – 7Fr Sheath. - Anterior Right Jugular Vein: Pacemaker – 8.5 Fr Sheath.

STRATEGY: - Left Femoral Artery approach (6Fr, “higher stick”). - XB 3.5 guiding catheter to left main. - 0.014’’ wire and 3.5x15 balloon advanced to mid third left anterior descending artery.

XB catheter

0.014’’wire

Pig Tail

0.035’’ Extra Stiff wire

Balloon

Pacemaker


TAVI Implantation

Patent Left main with TIMI 3 flow

Balloon expandable 23 mm valve


CONCLUSIONS • •

Left main occlusion is a rare (0,66%) but deadly complication of TAVI1 Predictors for left main occlusion include: • Female sex1 • Balloon expandable valve1 • Valve-in-valve1 • Lower distance to coronary ostium (<10 mm) 1 • ‘White line sign’2 • Leaflet lengh-to-coronary sinus lengh ratio3

• Pre-implantation valvuloplasty is an important tool for clinical decision making, especially in: - Decision on whether to protect the left main - Borderline valve sizing • Heart Team is a continous process present before TAVI (indication), during TAVI (implantation) and after TAVI (follow-up). 1J

2Circ

Cardiovasc Interv. 2017;10:e005011.

Am Coll Cardiol. 2013 Oct 22;62(17):1552-62. Interv. 2013 Nov 1;82(5):E754-9

3Catheter Cardiovasc


Case #3 Late heart valve thrombosis after transapical TAVI with a selfexpandable valve with stabilization arches SEROPIAN I.1, FALCONI M.1, LEADEN Y. 2, LEITE F.1, LASAVE L.2, KOTOWICZ V.1, AGATIELLO C.1, DAMONTE A.2, BERROCAL D.1 1Hospital 2Instituto

Italiano de Buenos Aires, Argentina Cardiovascular de Rosario, Santa Fe, Argentina


Clinical Background Female, 88 years old with severe aortic stenosis in NYHA III with preserved ejection fraction. Hypertension, hyperlipidemia, non-insulin-dependent type 2 diabetes. •2008: NSTEMI PCI with 1 DES to right coronary artery •2011: NSTEMI  PCI with 1 DES to left circumflex artery •Peripheral Vascular Disease: Bilateral asymptomatic left internal carotid severe stenosis (ultrasound)

•STS: 3.23% Euroscore II: 2.33% Frailty Score: 3/5


PRE-TAVI STUDIES

Echo: Max Grad. 73 mmHg, Mean Grad. 44 mmHg, valve area 0.6 cm2/m2, EF 65%, mild aortic insuffiiciency Echo: Max Grad. 73 mmHg, Mean Grad. 44 mmHg, valve area 0.6 cm2/m2, EF 65%, mild aortic regurgitation, SWT 15 mm

Left Coronary Artery: No obstructive coronary artery disease. Patent mid third LCx stent

Right Carotid Artery 49% stenosis

Left Carotid Artery 95% stenosis

Right Coronary Artery: 80% proximal stenosis Patent distal stent


PRE-TAVI STUDIES

Area: 321 mm2 Max. Diam: 23 mm - Min Diam: 20 mm

Aortic Sinus: 27.7x27.7x29 mm

Left coronay artery height: 9 mm

Balloon Aortic Valvuloplasty (8 months before TAVI)

20x40 mm compliant balloon Peak Gradient: 55 mmHg ď&#x192; 20 mmHg

Patent lef main with TIMI 3 flow during valvuloplasty


TAVI Procedure • General anesthesia with under TEE • Surgical Transapical approach: 33Fr – Delivery system. • Epicardial pacing. • Transapical approach due to borderline femoral arteries (6 mm) and soft atherosclerotic plaques at abdominal aorta.

Self expandable, nitinol valve with stabilization arches - “Small” size

Mild Paravalvular leak Aortic Gradient 10/5 mmHg


FOLLOW UP • • • •

Patient discharged on Clopidogrel 75 mg q.d. and Aspirin 100 mg q.d. Discharge Echo with preserved EF%, aortic gradients (mean 7 mmHg, max 12 mmHg) with mild regurgitation. 20 days after TAVI: Complete AV block  VVI Pacemaker implanted. 3 months after TAVI: Progresive dyspnea (NYHA III)

Left Coronary Artery: No obstructive coronary artery disease. Patent stent at mid third LCx

Right Coronary Artery: 80% proximal stenosis Patent distal stent


ECHOCARDIOGRAM TTE

• High aortic gradient through aortic prosthesis • Max Grad: 74 mmHg, Mean Grad: 50 mmHg • Mild aortic regurgitation

TEE

Thickened valve leaflets in long axis view


Gated MDCT

HALT images (Hypo Attenuated Leaflets Thickened) In short axis view

Thickened leaflets (HALT) in short axis view and restricted opening (RLM) during systole.


FOLLOW-UP TTE (2.5 months of anticoagulation)

Patient started anticoagulation (coumadin) with prompt improvement in symptoms.

Patient refused control MDCT - Continued on coumadin


SUMMARY • Clnical leaflets valve thrombosis after TAVI is rare condition (0.5-2.8%)1,2, but subclinical thrombosis is more frequent (10-15%)3. Late (>3 months) is the most prevalent form of presentation (72%)1,2 • Factors associated with thrombosis include: • Balloon expandable valve²,3 • Valve-in-valve2 • Absense of anticoagulation2,3 • Age3 • Reduced EF%3 • 4D volume-rendered CT is the ‘gold standard’ study for diagnostis (early hypoattenuated leaflet thickening and reduced or lack of leaflet motion)2-4 • Anticoagulation is the treatment of choice, succesfull in almost all cases4. 1 Structural

Heart 2017 Cardiovasc Interv. 2017;10(7):686-697. 3Lancet. 2017;389(10087):2383-2392 4N Engl J Med 2015;373:2015-24 5J Am Coll Cardiol 2017;69(17):2193-211 2JACC


The complexity of TAVI population Risk of thrombotic events • 1/3 prior coronary stent • 1/3 any type of AF • 1/3 previous stroke/TIA • > 1/3 previous CABG.

Risk of bleeding • Mean age ≈ 80. • > 1/10 renal failure • 1/3 anemia • 3/4 hypertension Genereaux P, et al. J Am Coll Cardiol 2012;59:2317-1607. Pagnesi M, et al. Inj J Cardiol 2016;221:97-106. Rodes-Cabau J, et al. J Am Coll Cardiol 2013;62:2349-2359.


Antithrombotic Therapy Post-TAVI Guidelines


Anticoagulation for Prosthetic Valves


Antithrombotic Therapy Post-TAVI Guidelines Recommendations

COR LOE

New: A lower target INR of 1.5 to 2.0 may be reasonable in patients with mechanical On-X AVR IIb B-R and no thromboembolic risk factors New: Anticoagulation with a VKA to achieve an INR of 2.5 may be reasonable for at least 3 IIb B-NR months after TAVR in patients at low risk of bleeding Clopidogrel 75 mg daily may be reasonable for the first 6 months after TAVR in addition to lifeIIb C long aspirin 75 mg to 100 mg daily Anticoagulant therapy with oral direct thrombin III: inhibitors or anti-Xa agents should not be used in B Harm patients with mechanical valve prostheses


2017 ACC/AHA Guidelines for TAVR

Bonow R. et al. Circulation 2017


Antithrombotic Therapy Post-TAVI Guidelines


Normal leaflets

Thickened leaflets with thrombus

Systole

Systole

Diastole

Diastole


Prevalence of HALT baseline and follow-up scan


La reducción de movilidad de valvas se observo en todas las prótesis incluidas las quirúrgicas

Corevalve

Diastole

Systole

Portico

Sapien

Perimount surgical valve


Evolution del fenómeno trombosis valvar Reduccion de movilidad a 30 días

Paciente con Warfarina Resolución de movilidad a 7 meses

Reducción de movilidad a 30 días

Paciente fuera rango 7 meses mas tarde

Reduced mobility

Persistencia trombo


Rationale for ASA+ Clopidogrel after TAVI

Profile for solacisocime18

Carla Agatiello | Complicación en TAVI  

Carla Agatiello | Complicación en TAVI  

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