Case Report: TAVI (biological aortic valve replacement via groin access) was performed on a 78-year-old patient with severe aortic stenosis (narrowing) and a left ventricular ejection fraction (heart pumping power) of 35%. However, when his complaints did not improve, serious leakage (paravalvular leak) was observed in the valve implanted after 1 month and TAVI (2nd implantation) was performed once more.
Case: A 78-year-old male patient was admitted to a fully equipped hospital with severe aortic stenosis and insufficiency, and as a result of the examinations, the left ventricular ejection fraction (EF value, which indicates the contraction rate of the left heart) was determined to be around 35%. In addition to heart failure, the patient also had compensated renal failure (Creatinine 1.6 mg/dl). Considering his age and general condition, it was decided to implant TAVI in the patient, but after the TAVI implantation, the patient’s complaints did not improve and even increased, and he applied to the same hospital again. In the examination, the patient was diagnosed with severe aortic insufficiency, and a “Valve in Valve”, or 2nd TAVI valve, was implanted to try to eliminate the insufficiency. However, the patient did not benefit from this procedure either, and his complaints increased and other complications were added. In addition, the patient developed cerebral embolism (blood clot in the brain), speech and walking disorders occurred, renal failure became severe (Creatinine 3.1 mg/dl) and Left Ventricular Ejection Fraction decreased to 25%. In the echocardiography, in addition to severe aortic insufficiency, severe mitral insufficiency occurred and in addition to these findings, a small Ventricular Septal Defect (VSD, a hole between the two heart chambers) developed.
Surgical Procedure: In the surgery performed with Median Sternotomy and cardiopulmonary bypass, the 2 TAVI biological valves seen in the picture were removed, the aortic valve was replaced with a conventional biological valve, the mitral valve was repaired by applying the annuloplasty method with a ring, and the small VSD was closed with the direct suture method. During the surgery, it was determined that the first TAVI approached the ventricular side of the anterior leaflet of the mitral valve, causing restriction of this leaflet, as well as causing a perforation (tear) on the corpus side of the leaflet. It is also estimated that the VSD that occurred was caused by a perforation in the membranous septum. The total cardiac arrest time was determined as 78 minutes and the cardiopulmonary bypass time as 96 minutes.
Postoperative Period: After the operation, the patient was observed in the intensive care unit for a total of 1 day and was discharged on the 7th day. Postoperative Creatinine values decreased to 1.1 mg/dl, no leakage was detected in the Aortic and Mitral valves in Echocardiography, and the EF value increased to 40% again.
Discussion and Conclusion: The indications for TAVI implantation should be seriously examined and the possible complications should be known in detail by the patients who will accept the treatment. It should be accepted that patients who are considered to be at risk for open surgery are actually at risk for TAVI and the indication area should be shifted to lower risk patients who inevitably need a biological valve (e.g. women considering pregnancy). As in this case, the removal of a TAVI (Explantation) is more difficult than a normal aortic valve surgery but is possible. However, it should not be forgotten that very high risk open heart surgeries are still the “Gold Standard” in experienced hands (1-2).
Resources :
1) Neurologic Complications of Unprotected Transcatheter Aortic Valve Implantation (from the Neuro-TAVI Trial). Am J Cardiol. 2016 Nov 15;118(10):1519-1526 Am J Cardiol. 2016 Nov 15;118(10):1519-1526
