Tsuda Masaki, Shutta Ryu, Nishino Masami, Tanouchi Jun
Division of Cardiology, Osaka Rosai Hospital, 1179-3 Nagasone-cho, Sakai, Osaka, Japan.
Eur Heart J Case Rep. 2020 Dec 15;5(1):ytaa497. doi: 10.1093/ehjcr/ytaa497. eCollection 2021 Jan.
Transcatheter aortic valve embolization is one of the serious complications of transcatheter aortic valve implantation (TAVI). We present a case of TAVI that needed implantation of three transcatheter aortic valves owing to the embolization of two self-expandable valves (SEVs).
An 88-year-old woman underwent TAVI using a 26-mm SEV. After valve deployment, the SEV embolized to the ascending aorta during the removal of the delivery system (DS) of the SEV (DS-SEV) from the SEV. An additional SEV was implanted, which also embolized upwards. Multi-directional fluoroscopy revealed extreme under-expansion of the second SEV, which caused valve embolization due to catching of the DS-SEVs in the SEVs. Finally, a 23-mm balloon-expandable valve was successfully implanted, which was also under expanded on fluoroscopic assessment. The patient was stable without sequelae at the 1-month follow-up.
Pre-procedurally predicting SEV under-expansions was difficult because pre-procedural computed tomography revealed no massive calcification on the aortic valve, and fluoroscopy indicated adequate expansion of the SEVs at the angle where the valves were deployed. We verified the possibility of catching of a DS-SEV in an under-expanded SEV in an test, which showed that the DS-SEV was caught in the extremely under-expanded SEV. Furthermore, balloon dilation might release the catch of the DS-SEV by changing the DS-SEV position. Therefore, we recommend performing multi-directional fluoroscopy to evaluate SEV expansion before DS-SEV removal from an SEV. Furthermore, if catching of a DS-SEV occurs, balloon dilation might be useful for releasing the catch and safely removing the DS-SEV.
经导管主动脉瓣栓塞是经导管主动脉瓣植入术（TAVI）的严重并发症之一。我们报告一例TAVI病例，该病例因两枚自膨式瓣膜（SEV）发生栓塞而需要植入三枚经导管主动脉瓣。
一名88岁女性接受了使用26毫米SEV的TAVI手术。瓣膜释放后，在从SEV移除自膨式瓣膜输送系统（DS-SEV）的过程中，SEV栓塞至升主动脉。随后植入了另一枚SEV，但该瓣膜也向上栓塞。多方向透视显示第二枚SEV极度未充分扩张，这导致DS-SEV卡在SEV中，从而引起瓣膜栓塞。最后，成功植入了一枚23毫米球囊扩张瓣膜，透视评估显示该瓣膜也未充分扩张。患者在1个月随访时情况稳定，无后遗症。
术前难以预测SEV未充分扩张，因为术前计算机断层扫描显示主动脉瓣无大量钙化，且透视显示在瓣膜释放角度处SEV扩张充分。我们在一项测试中验证了DS-SEV卡在未充分扩张的SEV中的可能性，该测试表明DS-SEV卡在极度未充分扩张的SEV中。此外，球囊扩张可能通过改变DS-SEV的位置来解除其卡滞。因此，我们建议在从SEV移除DS-SEV之前，进行多方向透视以评估SEV的扩张情况。此外，如果发生DS-SEV卡滞，球囊扩张可能有助于解除卡滞并安全移除DS-SEV。
