International Society For Minimally Invasive Cardiothoracic Surgery

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Alignment Difficulty And Balloon Rupture Of A Sapien 3
Gentaku Hama.
Saku Central Hospital, Saku, Japan.

BACKGROUND - Transcatheter aortic valve implantation (TAVI) has become an alternative technique to treat aortic stenosis (AS) in patients with high surgical risk. However, TAVI remains associated with potentially life-threatening complications. We report a case with a rare complication of TAVI. METHODS- A 83-year old female with a history of hypertension, permanent pacemaker and severe AS was referred to our center for TAVI. The logistic EuroSCORE predicted the mortality of 13.15%. Transthoracic echocardiography demonstrated very severe aortic stenosis (aortic valve area 0.3cm2, mean aortic valve gradient 50mmHg) and preserved left ventricular ejection fraction. Computed tomography revealed that the aortic annulus size was 25.1 x 18.8 mm with an area of 374mm2 and tortuous aorta. It was subsequently decided that TAVI should be done using an Edwards SAPIEN 3 (S3) 23 mm valve (Edwards Lifescience, Irvine, California) via a right femoral approach. RESULTS - After a 23mm S3 was advanced into descending aorta over a Safari Guidewire (Boston Scientific, Marlborough, Massachusetts), the finealignment-wheel was not functioning and blood was entering the inflation device. An attempt to remove the commander delivery system (Edwards Lifescience) through the 14-Fr expandable e-sheath (Edwards Lifescience) was not successful. Then, it was decided to remove the sheath and the valve together. However, the valve was stuck at the right common iliac artery and arteriography showed localized dissection. An emergency laparotomy was performed to retrieve the device, and another 23 mm S3 was implanted successfully over a Lunderquist wire (Cook Medical, Bloomington, Indiana) thorough the left femoral artery. The patient was discharged on day 14. CONCLUSIONS - Caution should be taken when using a balloon expandable device in a tortuous aorta to avoid life-threatening complications from alignment difficulty.

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