TAVI complication. Possible aetiology and how to manage
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1 TAVI complication. Possible aetiology and how to manage Dr Sanjeevan Pasupati Waikato Hospital, Hamilton, New Zealand Operators: Dr Sanjeevan Pasupati, Mr Nand Kejriwal, Mr Adam Elgamel
2 Valve Positioning 1 Aortic 2 Good 3 Ventricular
3 Valve deployment Valve final
4 PL 67Y Female Severe Symptomatic AS NYHA 3 SOB. No Angina, No Syncope Echo: APG81mmHg, AMG55mmHg, AVA0.7cm 2,DI0.18. Cath: APG38mmHg, AMG42mmHg, AVA0.6cm 2 Right heart pressures: mild elevation at 40mmHg. EF65%
5 PL 67Y Female Past CABG (2001): LIMA-LAD, Free RIMA_PDA, RA-OM -all patent t T2DM, HT, Dyslipidaemia. Doppler: 60% RCA stenosis. CT Chest: right ventricle is tightly applied to the back of the sternum LIMA stuck to the sternum. Heavily calcified aortic root. Referred for TAVI based on CT results
6
7 Calcified aortic root TAVI assessment
8 CT scan Calcified STJ with minimally Calcified STJ with minimally calcified Aortic valve leaflets
9 TAVI assessment Minimal calcification on the aortic valve STJ calcification Aortic Annulus: 20-21mm
10 TAVI assessment STJ 20mm Vessels too small for arterial access
11 TAVI assessment Accepted for 23mm ESV via transapical approach
12 Procedure General anaesthesia Trans oesophageal guidance Transapical 26Fr sheath. RFA & RFV 6Fr. Temporary pacing wire in RV. Pigtail in Aortic root
13 BAV 20mmx3cm Edwards balloon. Rapid pacing 200bpm.
14 Valve Positioning
15 Valve deployment Valve final Rapid pacing at 200bpm
16 Patient hemodynamically stable Valve final position MR3+
17 Final valve position TAVI Native
18 What s next
19 Management of Malposition We decided to place a second valve to relive the aortic stenosis and also to stabilize the first valve. Just before placing the second valve, the first valve fell into the left ventricle.
20 What s next Valve retrieval: No Valve has been successfully retrieved via the apex Surgical AVR: Unable to stitch a new valve without root reconstruction LIMA stuck to the sternum We decided to place the second valve and retrieve the first valve via the left atrium with a lateral thoracotomy.
21 What we did
22 What s next
23 Reposition by Balloon
24 Reposition by Balloon
25 What s next
26
27 Taken to the operating room Sternotomy to avoid LIMA. Bypass Femoral artery LV apex. Valve 2 retrieved. Valve 1 repositioned and deployed under direct vision. Aorta successfully closed with pericardial patch. Patient t left OR with minimal i inotropic and ventilatory support.
28 Aetiology of valve malposition 20mm 18mm 23mm ESV is implanted using a 22mm Balloon
29 Aetiology of valve malposition 20mmx3cm Edwards balloon. Rapid pacing 200bpm.
30 Management of ventricular migration of ESV Valve in LVOT Valve in LV
31 AVOID: Reposition by Balloon
32 Valve in LVOT: Implant a second valve to stabilize the first valve and treat aortic stenosis
33 AVOID: Taking the second valve transapically
34 Valve in left ventricle Take the second valve via the LA or Aorta
35 Management of ventricular migration of ESV Avoid: Re-positioning a fully deployed valve with a balloon Taking the second valve transapically Consider: Implanting a second valve to stabilize the first valve. Always take the second valve via the LA or Aorta
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