Aortic Root Rupture during Transcatheter Aortic Valve Implantation in a Patient with Idiopathic Thrombocytopenic Purpura: Utility of Transesophageal Echocardiography in Early Detection and Description of a Semiconservative Surgical Management Approach

Abstract

An 87-year-old man with idiopathic thrombocytopenic purpura and platelet count of 56 × 10⁹/L underwent transesophageal echocardiography (TEE)–guided transcatheter aortic valve implantation using a femoral approach. Post valve deployment, a new pericardial effusion was noted which was successfully drained. Despite this, the patient became hypotensive needing vasopressor support with reaccumulation of pericardial fluid. Emergent sternotomy was performed and a perforation of the right ventricular apex was noted which was sealed with a pledgeted suture. Continued bleeding prompted further exploration; the aorta was seen to be mottled in conjunction with clear aortic root hematoma on TEE and a diagnosis of root rupture was made. This was semiconservatively managed without conversion to a full aortic root repair or replacement procedure. Multiple sutures were applied to the periaortic space and the bleeding sealed with use of BioGlue (Cryolife Inc., Kennesaw, GA) and Surgicel (Ethicon Inc., Somerville, NJ). The postoperative course was stable and the patient remained well at 3-month follow-up.

Keywords

aortic valve stenosis - percutaneous aortic valve replacement - emergent sternotomy - surgical conversion - pericardiocentesis

• References

• 1 Sinning JM, Hammerstingl C, Vasa-Nicotera M , et al. Aortic regurgitation index defines severity of peri-prosthetic regurgitation and predicts outcome in patients after transcatheter aortic valve implantation. J Am Coll Cardiol 2012; 59 (13) 1134-1141
• 2 Berdajs D. Aortic root rupture: implications of catheter-guided aortic valve replacement. Curr Opin Cardiol 2013; 28 (6) 632-638
• 3 Yu Y, Vallely M, Ng MK. Valve-in-valve implantation for aortic annular rupture complicating transcatheter aortic valve replacement (TAVR). J Invasive Cardiol 2013; 25 (8) 409-410
• 4 Lee L, Henderson R, Baig K. Successful treatment of aortic root rupture following transcatheter aortic valve implantation in a heavily calcified aorta: A novel approach to a serious complication. Catheter Cardiovasc Interv 2012
• 5 Pasic M, Unbehaun A, Dreysse S , et al. Rupture of the device landing zone during transcatheter aortic valve implantation: a life-threatening but treatable complication. Circ Cardiovasc Interv 2012; 5 (3) 424-432
• 6 Blanke P, Reinöhl J, Schlensak C , et al. Prosthesis oversizing in balloon-expandable transcatheter aortic valve implantation is associated with contained rupture of the aortic root. Circ Cardiovasc Interv 2012; 5 (4) 540-548
• 7 Blanke P, Willson AB, Webb JG , et al. Oversizing in transcatheter aortic valve replacement, a commonly used term but a poorly understood one: dependency on definition and geometrical measurements. J Cardiovasc Comput Tomogr 2014; 8 (1) 67-76
• 8 Gabay M, Boucher BA. An essential primer for understanding the role of topical hemostats, surgical sealants, and adhesives for maintaining hemostasis. Pharmacotherapy 2013; 33 (9) 935-955
• 9 Yamamoto M, Meguro K, Mouillet G , et al. Effect of local anesthetic management with conscious sedation in patients undergoing transcatheter aortic valve implantation. Am J Cardiol 2013; 111 (1) 94-99
• 10 Ben-Dor I, Looser PM, Maluenda G , et al. Transcatheter aortic valve replacement under monitored anesthesia care versus general anesthesia with intubation. Cardiovasc Revasc Med 2012; 13 (4) 207-210
• 11 Smith LA, Monaghan MJ. Monitoring of procedures: peri-interventional echo assessment for transcatheter aortic valve implantation. Eur Heart J Cardiovasc Imaging 2013; 14 (9) 840-850