Cardiac perforation following transcatheter aortic valve implantation
1 week s/p left femoral transcatheter aortic valve implantation (TAVI) and complained about pain in his right groin
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To rule out retroperitoneal hematoma, CT of the abdomen was performed with incidental cardiac findings as described below.
There is a hematoma in the left groin after the femoral artery was used for access during transfemoral TAVI. However, extracorporal compression of that region has already been applied.
A very important incidental finding is the rupture of the dorsal part of the left ventricle. Contrast agent leaks through a small gap in the dorsal myocardium of the left ventricle and aggregates in a 4.6 x 2.1 measuring hole.
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The perforated region of left ventricle is indicated by the blue arrowhead, where contrast is observed traversing the myocardium.
2 case questions available
Transcatheter aortic valve implantation (TAVI) has become a common procedure for treatment of aortic valve stenosis, especially in patients with an increased risk for major adverse cardiac events during conventional aortic valve implantation using thoracotomy. While TAVI has been shown to reduce the periprocedural life-threatening risks, there are still several complications that can occur.
This case is particularly interesting as the patient did not report any cardiac symptoms and complained rather about pain in the contralateral right groin. Therefore, postinterventional ultrasound studies of the heart can sometimes be helpful to detect silent postprocedural complications.
When using the transfemoral approach, vascular injuries are the major risk with reported rates of 11.7% for dissection, occlusion and perforation. Preoperative CT of the major vessels improves planning of the procedure and can reduce the perioperative complication rates and is therefore routinely performed atour institution. However, the learning curve is steep and major adverse events can occur, especially since this technique is usually performed on a high-risk patient cohort.
- Moat NE, Ludman P, de Belder MA et al. Long-term outcomes after transcatheter aortic valve implantation in high-risk patients with severe aortic stenosis: the U.K. TAVI (United Kingdom Transcatheter Aortic Valve Implantation) Registry. J Am Coll Cardiol. 2011 Nov 8;58(20):2130-8. doi:10.1016/j.jacc.2011.08.050 - Pubmed citation
- Gurvitch R, Tay EL, Wijesinghe N et al. Transcatheter aortic valve implantation: lessons from the learning curve of the first 270 high-risk patients. Catheter Cardiovasc Interv. 2011 Dec 1;78(7):977-84. doi:10.1002/ccd.22961 - Pubmed citation
- Johansson M, Nozohoor S, Kimblad PO et al. Transapical versus transfemoral aortic valve implantation: a comparison of survival and safety. Ann Thorac Surg. 2011 Jan;91(1):57-63. doi:10.1016/j.athoracsur.2010.07.072 - Pubmed citation
- Aminian A, Lalmand J, El Nakadi B. et al. Perforation of the descending thoracic aorta during transcatheter aortic valve implantation (TAVI): an unexpected and dramatic procedural complication. Catheter Cardiovasc Interv. 2011 Jun 1;77(7):1076-8. doi:10.1002/ccd.22960 - Pubmed citation
- Clavel MA, Webb JG, Rodés-Cabau J et al. Comparison between transcatheter and surgical prosthetic valve implantation in patients with severe aortic stenosis and reduced left ventricular ejection fraction. Circulation. 2010 Nov 9;122(19):1928-36. doi:10.1161/CIRCULATIONAHA.109.929893 - Pubmed citation