Kitaura Atsuhiro, Sakamoto Hiroatsu, Tsukimoto Shota, Yuasa Haruyuki, Nakajima Yasufumi
Anesthesiology, Kindai University Faculty of Medicine, Osaka, JPN.
Dental Anesthesiology, Kanagawa Dental University, Yokosuka, JPN.
Cureus. 2024 Jun 12;16(6):e62266. doi: 10.7759/cureus.62266. eCollection 2024 Jun.
Surgical aortic valve replacement (SAVR) is the recommended curative treatment for pure native aortic regurgitation (AR). However, some patients are not suitable for SAVR due to comorbidities or frailty. Transcatheter aortic valve replacement (TAVR) has been reported to offer a better prognosis than medical therapy in AR patients; thus, the use of TAVR for AR may increase in the future. However, the reduced calcification and annulus ring stiffness associated with TAVR may increase the risk of valve migration. Accumulating data on rescue measures in the event of valve migration is necessary. An 87-year-old female with a history of hypertension and persistent atrial fibrillation presented to our emergency department with dyspnea. The patient was diagnosed with congestive heart failure class IV, according to the New York Heart Association classification, necessitating urgent admission to our cardiac department. Due to the patient's high surgical risk (Society of Thoracic Surgeons (STS) score 9.17%, Euro2 score 9.55%, frailty 6), the heart team performed TAVR with a right femoral arterial approach. The patient was sedated, and pacing was initiated at 180 bpm. We placed an Edwards SAPIEN 3 valve (Edwards Lifesciences, Irvine, CA, USA) #23 (-1 mL volume, with attached balloon). During the post-deployment procedure, the aortic valve migrated retrogradely into the left ventricle (LV). Despite the occurrence of severe aortic valve regurgitation, the patient's vital signs remained stable. Five minutes after the migration of the aortic valve, venoarterial extracorporeal membrane oxygenation (VA-ECMO) was initiated. A second TAVR valve implantation was then performed. However, after the second valve implantation and the removal of the pre-shaped guidewire (Safari pre-shaped guidewire extra small, Boston Scientific, Marlborough, MA, USA), the migrated valve became stuck in the left ventricular outflow tract (LVOT) in a reverse position, resulting in severely limited left ventricular ejection. We increased the support provided by VA-ECMO, and surgical conversion to SAVR was performed without experiencing circulatory collapse. Surgical aortic valve replacement was initiated successfully, and withdrawal of the cardiopulmonary bypass (CPB) was performed without complications. The patient was extubated on the first postoperative day (POD), discharged from the ICU on POD 3, and transferred for rehabilitation on POD 27. In summary, the prompt introduction of VA-ECMO was important for avoiding complications and saving the patient's life following the retrograde migration of the TAVR valve.
外科主动脉瓣置换术（SAVR）是单纯原发性主动脉瓣反流（AR）的推荐治疗方法。然而，一些患者由于合并症或身体虚弱而不适合进行SAVR。据报道，经导管主动脉瓣置换术（TAVR）在AR患者中的预后优于药物治疗；因此，未来TAVR在AR中的应用可能会增加。然而，与TAVR相关的钙化减少和瓣环僵硬可能会增加瓣膜移位的风险。积累瓣膜移位时的抢救措施数据很有必要。一名87岁女性，有高血压和持续性房颤病史，因呼吸困难就诊于我院急诊科。根据纽约心脏协会分类，该患者被诊断为IV级充血性心力衰竭，需要紧急入住我院心脏科。由于患者手术风险高（胸外科医师协会（STS）评分9.17%，Euro2评分9.55%，身体虚弱6级），心脏团队采用右股动脉入路进行了TAVR。患者接受镇静，以180次/分钟的频率开始起搏。我们植入了一枚Edwards SAPIEN 3瓣膜（美国加利福尼亚州尔湾市Edwards Lifesciences公司生产）#23（-1 mL容积，附带球囊）。在瓣膜植入后操作过程中，主动脉瓣逆行移入左心室（LV）。尽管出现了严重的主动脉瓣反流，但患者的生命体征保持稳定。主动脉瓣移位5分钟后，启动了静脉-动脉体外膜肺氧合（VA-ECMO）。然后进行了第二次TAVR瓣膜植入。然而，在第二次瓣膜植入并移除预塑形导丝（美国马萨诸塞州马尔伯勒市波士顿科学公司生产的Safari预塑形超细导丝）后，移位的瓣膜以相反的位置卡在左心室流出道（LVOT），导致左心室射血严重受限。我们增加了VA-ECMO的支持，并成功进行了转为SAVR的手术，未出现循环衰竭。成功启动了外科主动脉瓣置换术，体外循环（CPB）撤离过程中未出现并发症。患者术后第1天拔管，术后第3天从重症监护病房出院，术后第27天转至康复科。总之，在TAVR瓣膜逆行移位后，迅速引入VA-ECMO对于避免并发症和挽救患者生命非常重要。
