Cardiac perforation following transcatheter aortic valve implantation

Case contributed by Julian L. Wichmann
Diagnosis certain


1 week s/p left femoral transcatheter aortic valve implantation (TAVI) and complained about pain in his right groin

Patient Data

Age: 70 years
Gender: Male

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 cm measuring hole.

The perforated region of left ventricle is indicated by the blue arrowhead, where contrast is observed traversing the myocardium. 

Case Discussion

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.

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