History. 2D echo before TAVI. 88 female Hypertensive - hyperlipidemic History of LOC syncope Echo: severe AS AV gradient 90 mmhg Good LV LVH

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2 History 88 female Hypertensive - hyperlipidemic History of LOC syncope Echo: severe AS AV gradient 90 mmhg Good LV LVH 2D echo before TAVI LHC: Normal cors

4 Pre severe calcification LVOT calcification

5 DEPLOYMENT

6 DEPLOYMENT

7 DEPLOYMENT

8 Immediately post deployment: incomplete apposition and moderate AR

9 QUESTION 1 FURTHER MANAGEMENT A. leave AR manage conservatively B. post dilatation balloon 20mm C. post dilatation balloon 22mm D. post dilatation balloon 24mm

10 QUESTION 1 FURTHER MANAGEMENT A. leave AR manage conservatively B. post dilatation balloon 20mm C. post dilatation balloon 22mm D. post dilatation balloon 24mm

11 Post dilation semi-compliant balloon 22mm

12 Immediately post dilatation patient became hypotensive; A large pericardial effusion with tamponade was noted;

13 Aortogram showed intraannular rupture with minimal residual AR

14 QUESTION 2 FURTHER MANAGEMENT A. Operation B. Pericardial drainage and operation C. Pericardial drainage and continue antiplatelets antithrombotics D. Pericardial drainage and discontinue antiplatelets antithrombotics

15 QUESTION 2 FURTHER MANAGEMENT A. Operation B. Pericardial drainage and operation C. Pericardial drainage and continue antiplatelets antithrombotics D. Pericardial drainage and discontinue antiplatelets antithrombotics

16 Patient was treated conservatively with pericardial drainage, heparin reversal, interruption of all antithrombotics- antiplatelets and immobilization In consultation with cardiac surgeons and getting advice from TAVI forum, we did not start any antithrombotics-antiplatelets for 6 days Pericardial effusion disappeared and drain removed day number 5

17 Day number 6, patient developed TIA with dysphasia, CT was normal;

18 QUESTION 3 FURTHER MANAGEMENT A. aspirin B. antithrombotics C. Dual antiplatelets D. no antiplatelets - antithrombotics

19 QUESTION 3 FURTHER MANAGEMENT A. aspirin B. antithrombotics C. Dual antiplatelets D. no antiplatelets - antithrombotics

20 Day number 6, patient developed TIA with dysphasia, CT was normal; started on Aspirin and TIA resolved completely. She started mobilization.

21 Day number 12, patient developed signs of pulmonary embolism. CT showed left lower lobe thrombi. CT aortogram did not show paraaortic false aneurysm

22 QUESTION 4 FURTHER MANAGEMENT A. continue with aspirin add sc heparin B. change aspirin to sc heparin C. change aspirin to oral antithrombotics D. continue with aspirin add oral antithrombotics

23 QUESTION 4 FURTHER MANAGEMENT A. continue with aspirin add sc heparin B. change aspirin to sc heparin C. change aspirin to oral antithrombotics D. continue with aspirin add oral antithrombotics

CT aortogram did not show paraaortic false aneurysm.

24 Day number 12, patient developed signs of pulmonary embolism. CT showed left lower lobe thrombi. CT aortogram did not show paraaortic false aneurysm. She was started on sc heparin in addition to aspirin and clinical picture improved

Subcutaneous heparin is stopped; patient remains on long term aspirin 2D echo 2

25 Patient discharged day number 14 on aspirin and subcutaneous heparin 2 months later remained fully asymptomatic Echo shows no pericardial fluid and minimal AR Subcutaneous heparin is stopped; patient remains on long term aspirin 2D echo 2 months later no pericardial fluid Colour echo 2 months later minimal paravalvular AR

26 3 months later Severe UTI acute renal failure Iv fluids iv antibiotics Renal function fully restored

27 4 months later Chest pain - SOB

28 CRP > 10X INCREASED WCC

29 QUESTION 5 DIAGNOSIS A. Relapse of rupture B. viral pericarditis C. late DRESSLER S

30 QUESTION 5 DIAGNOSIS A. Relapse of rupture B. viral pericarditis C. late DRESSLER S

31 CRP > 10X INCREASE WCC LATE DRESSLER S: STEROIDS + COLCHICINE

32 15 DAYS AFTER STEROIDS pt very well steroids stopped colchicine continued NO PERICARDIAL EFFUSION TRIVIAL AR

33 10 months post TAVI Asymptomatic Colchicine stopped ECHO: no pericardial effusion, TAVI functioning normally

34 1 year FU Pt alive and well TAVI normally functioning ONLY COMPLAIN: lower back pain

35 In conclusion Preventing Annulus Rupture Clinical judgment Good imaging pre TAVR (CT scan, calcifications esp LVOT) Avoid aggressive THV oversizing Avoid oversizing postdilatation balloon (as in our case) Prosthesis Selection (probably self expandable for LVOT calcification) Managing antithromboticsantiplatelets post annulus rupture Judicious use Gradual and staged onset Be aware of complications

36 2 st Case: 31 mm CoreValve- VF Arrest Deployment Aortogram Pre Deployment 1

37 Deployment 2 Deployment 3

38 Deployment 4 Deployment 5

39 Deployment 6 VF arrest- Quick Deployment

40 Final Result

41 Iliac Pre Iliac Post

42 Predictors Post dilation Oversizing 20% Calcifications (LVOT-Sub annular) Annulus Eccentricity? Prevention: Sizing/Slow inflation/self Expandable if adverse features present

43 1 st Case: Aortic rupture peri-tavi Acute or delayed aortic annular rupture is a rare (0-2%) but serious complication with a very poor prognosis, even if emergent surgery is performed Annular rupture may occur after balloon valvuloplasty after valve implantation (more frequently with balloon-expandable valves)

SAPIEN 3 Sizing Considerations:

SAPIEN 3 Sizing Considerations: Oversizing, Undersizing, or Volume reduction? John Webb MD St Paul s Hospital University of British Columbia Vancouver Disclosure Statement of Financial Interest Within