Othman Farrah, Yong Gerald, Whelan Alan, Ihdayhid Abdul Rahman
Department of Cardiology, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Perth, WA 6150, Australia.
Cardiovascular Research and Innovation Laboratory, Harry Perkins Institute of Medical Research, Perth, Australia.
Eur Heart J Case Rep. 2024 May 9;8(6):ytae226. doi: 10.1093/ehjcr/ytae226. eCollection 2024 Jun.
Iatrogenic aortic valve injury during cardiovascular catheterization interventions is extremely rare. Severe aortic regurgitation that ensues can be catastrophic and the management is typically with surgical valve replacement or repair. Percutaneous management of native pure aortic regurgitation is difficult due to anatomical challenges and the limitations of current transcatheter heart valve technology to anchor in the absence of leaflet or annular calcification.
An 82-year-old female underwent rotational atherectomy (RA) for a severely calcified stenosis of the left anterior descending artery. The patient was discharged well following placement of two drug eluting stents. She represented to hospital 7 days later with acute pulmonary oedema. Bedside transthoracic echocardiography demonstrated new, severe AR with preserved left ventricular size and function. Review of the prior percutaneous coronary intervention revealed significant trauma to the aortic valve during RA, with contrast seen refluxing into the LV during diastole, evolving throughout the procedure. Given the patient was not an operative candidate, an oversized transcatheter aortic valve was successfully implanted. In the post-operative setting, the patient suffered a stroke. Extensive hypoattenuated leaflet thickening (HALT) and thrombus was seen on dedicated 4D CT imaging. She made full neurological recovery and valve function returned to normal following a period of anticoagulation.
Although iatrogenic aortic valve laceration is rare, this case highlights several important learning points including the importance of good guide catheter support during RA; the feasibility of Transcatheter Aortic Valve Replacement for pure native AR; and the detection and management of HALT.
心血管导管介入治疗期间发生医源性主动脉瓣损伤极为罕见。由此引发的严重主动脉瓣反流可能是灾难性的，治疗通常采用外科瓣膜置换或修复。由于解剖学上的挑战以及当前经导管心脏瓣膜技术在无瓣叶或瓣环钙化情况下锚定的局限性，经皮治疗原发性单纯主动脉瓣反流较为困难。
一名82岁女性因左前降支严重钙化狭窄接受了旋磨术（RA）。植入两枚药物洗脱支架后患者顺利出院。7天后她因急性肺水肿再次入院。床旁经胸超声心动图显示出现新的严重主动脉瓣反流，左心室大小和功能保留。回顾先前的经皮冠状动脉介入治疗发现，RA期间主动脉瓣受到严重创伤，在整个手术过程中可见造影剂在舒张期反流至左心室。鉴于该患者不适合手术，成功植入了一枚超大号经导管主动脉瓣。术后患者发生了中风。在专门的4D CT成像上可见广泛的低衰减瓣叶增厚（HALT）和血栓形成。经过一段时间的抗凝治疗，她的神经功能完全恢复，瓣膜功能也恢复正常。
尽管医源性主动脉瓣撕裂很少见，但该病例突出了几个重要的经验教训，包括RA期间良好的引导导管支撑的重要性；经导管主动脉瓣置换治疗原发性单纯主动脉瓣反流的可行性；以及HALT的检测和处理。
