Postoperative occlusion of a transapical implanted valve due to mechanical CPR

Introduction: TAVI is an alternative treatment to surgical valve replacement in patients with high predicted risk for perioperative mortality. Possible complications were evaluated in several trials. We present a case of postoperative occlusion of a transapical implanted Edwards Sapien valve due to CPR at ICU.

Aims: Complications reported predominant are arterial injury, stroke, improper positioning, coronary obstruction, mitral valve injury, annulare and root rupture, cardiac perforation, heart block or arrhythmia. We would like to report about the postoperative total occlusion of a transapical implanted Edwards-Sapien valve due to CPR: An 83 year old female patient with a severe symptomatic low gradient aortic stenosis with an orifice of 0.51cm² was pretreated with a balloon valvuloplastie. TAVI was indicated because of several additional morbidities. A logistic Euro score of 40.2% was calculated and in agreement with the cardiologists a TAVI-procedure was decided. In ICU she was in cardiopulmonary sufficient state with low intropic support. The postoperative echocardiography showed no evidence of a pericardial effusion. During the following hour the patient showed tachycardia of 160 beats/min. The treatment with amiodarone showed slight reduction of frequency but hemodynamic parameter impaired acutely. CPR without any stabilisation of vital parameters was progressed. Despite of mechanical and medicamentous CPR flatline was resistant to extern pacemaker stimulation. The patient died seven hours postoperatively. The post-mortem examination showed regular surgical area with sufficient sutures in the region of the left ventricular apex. The correctly located valve prosthesis was distorted in consequence of the mechanical CPR and occluded the aortic outflow. A rupture of the right ventricle with a major bleeding was consequence of manual CPR. Cause of death was a hemorrhagic shock with the typical signs of multi organ disorder.

Discussion: The complication of postoperative occlusion of a transapical implanted Edwards-Sapien valve due CPR is not mentioned before. As the Edwards Sapien is not sewed in the aortic wall like the valves in surgical replacement, it seems that the valve after TAVI is more sensitive towards mechanical stress during CPR.