International Society For Minimally Invasive Cardiothoracic Surgery

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Valve Displacement Can Cause Alarming Complications After Transcatheter Aortic Valve Implantation (tavi)
Manoras M. Chengalath, Jr., Bhaskar Ranganathan, Jose Chacko Periappuram.
Lisie Heart Institute, Cochin, India.

Background Transcatheter aortic valve implantation (TAVI) is becoming a more common procedure for patients with aortic stenosis who have very high risk for operative intervention. Displacement of the device can be a dreaded complication. Case History A 79 years old gentleman with severe aortic stenosis was taken up for TAVI. When the valve got displaced into the ascending aorta, a second valve was deployed. Unfortunately this valve got displaced into the left ventricle. Efforts to snare and pull it out to an optimal position failed. After 9 hours of interventional efforts he was taken up for an emergency surgical exploration. The imminent dangers included huge doses of dye being used with impending kidney damage, a new onset left bundle branch block, calcifications in femoral artery, and catheterization images showing minimal space for cross clamping the aorta. Aortic canulla was put between the two prosthesis. On total circulatory arrest the aortic canulla was removed and the aorta was opened. There was a dissection flap in the ascending aorta which was excised. Both the prosthetic TAVI valves were removed. A 24 mm Hemashield interposition graft was anstomosed to the mouth of the aortic arch. A bioprosthetic valve replacement was done after removing the heavily calcific aortic valve. We encountered severe bleeding which required packing of pericardium with gauze and keeping chest open. We closed the chest the next day. He had a prolonged ICU stay with dialysis for his renal failure and tracheostomy for his prolonged ventilation. With intense physiotherapy and mobilization he was sent home after one month. Discussion All the major complications of valve displacement, aortic dissection, rhythm abnormalities and renal failure were seen in our patient. We could expect a surgical exploration if the TAVI valve fails to position itself in the correct position. Devices to snare and pull the displaced valve can cause physical damage to the compensated aortic valve and ascending aorta. Conclusions Valve technology for dealing with malpositions need to improve. Complications of placement of valve would become infrequent when operator skills improve. A high suspicion of ascending aorta dissection should be bore in mind while doing the procedure.

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