Aortic annulus rupture after transcatheter aortic valve replacement: successful management of a dangerous complication

84 year old female with a BMI of 23.1 and a history significant for coronary artery disease, stage 3 CKD, hypertension, hyperlipidemia, and a 16 pack-year history of smoking who presented for placement of a balloon expandable TAVR, size 29. Her preoperative aortic annulus measurements on CT scan were as follows: Short axis 22.6 mm, long axis 32.5 mm, area defined effective diameter 26.9, square area 570 mm². (Fig. 1) She was noted to have severe calcification of the aortic valve annulus. She was undergoing a subclavian approach when her annulus ruptured during balloon valvuloplasty prior to TAVR. The extravasation of contrast was not initially noted, but she rapidly became hypotensive within 5 min of valvuloplasty. An emergent echocardiogram was performed, and she was noted to have a pericardial effusion. She underwent a pericardiocentesis within 3 min of the initial hypotension event, which yielded blood, and transiently improved the blood pressure, but hemostasis was unable to be achieved even after reversal of anticoagulation. After 9 min of attempting hemostatic control, the decision was made to do an emergent sternotomy with surgical aortic valve replacement. 13 min after the initial hypotension event, a sternotomy was performed, and after 17 min from the initial hypotension event, the patient was placed on cardiopulmonary bypass. She underwent a surgical aortic valve replacement with a 23 mm bioprosthetic valve. She was noted on surgical opening to have damage to both the septum, inferior to the membranous septum, and annulus along the noncoronary sinus, as well as hematoma under the epicardial fat. Hemashield (Maquet, Wayne, NJ) patches were used to close the aorta and septum. Her chest was left open following the procedure with delayed closure on post-op day 2, with one pleural drain, and one mediastinal drain in place. She had multiple episodes of paroxysmal atrial fibrillation throughout her stay that ultimately resolved without further intervention. The remainder of her post-operative care was standard surgical aortic valve replacement care and was without complications. She was discharged to a skilled nursing rehabilitation facility on post-op day 15 and later returned home. At nearly one year follow-up, her surgical aortic valve was functioning normally, with no long term effusion.

82 year old female with a BMI of 31.0 and a history significant for diabetes, hypertension, and no smoking history who presented for TAVR with a balloon-expandable valve size 23. Her aortic annulus measurements were as follows: Short axis 21.0 mm, long axis 24.4 mm, area defined effective diameter 22.4 mm, square area 394 mm² (Fig. 2). Of note, her aortic valve was found to have only moderate calcification. She was undergoing a Left femoral approach and valve expansion when she became hypotensive with mean arterial pressure (MAP) as low as 30 mmHg. An emergent echocardiogram was performed, and she was noted to have pericardial effusion. A pericardiocentesis was performed that yielded 200 mL of blood. At that time, SURGIFLO (Johnson & Johnson Wound Management, Somerville, NJ) was injected into the pericardial space to gain hemostatic control (Fig. 3). Repeat aortic root angiography showed no further contrast extravasation. A pericardial drain was left in place for 2 days. Prior to its removal, a chest CT angiogram was obtained which showed no evidence of active extravasation of contrast dye. Her stay was further complicated by atrial fibrillation with rapid ventricular rate, which converted back to normal sinus rhythm with pharmacologic therapy. The remainder of her stay was uncomplicated, and she was discharged home on POD 7. An echocardiogram at one-month post-op showed no effusion and normal valve function.

88 year old female with a BMI of 20.4 and a history significant for coronary artery disease, with drug-eluting stent in her right coronary artery, hypertension, hyperlipidemia, and carotid stenosis, as well as osteoporosis, who presented for TAVR with a 23 mm balloon-expandable valve. Her aortic annulus measurements were as follows: Short axis 16.4 mm, long axis 30.3 mm, area defined effective diameter 22.1, square area 383 mm² (Fig. 4). Her aortic valve was found to have significant calcification, with the non-coronary leaflet showing severe calcification and mild calcification of the left coronary leaflet. She underwent a right transfemoral approach TAVR, which was deployed in good position, but initially had a mild to moderate paravalvular leak (PVL). At that time, the decision was made to post-dilate the valve further in an attempt to reduce PVL. Two minutes after the first dilation, the valve was dilated an additional 1 mm in diameter, and the procedure was completed. As the procedure was concluding, about 15 min after the second valve dilation, an echocardiogram was performed, and she was noted to have a new pericardial effusion (Fig. 5). She was re-prepped, and an emergent pericardiocentesis was performed, which yielded 500 cc of blood. She was intubated to facilitate a transesophageal echocardiogram and was diagnosed with a ruptured aortic root. The patient’s healthcare proxy and family declined emergent surgery, and thus a pericardial drain was placed, and arterial blood (determined by oxygen saturation) continued to be aspirated from the pericardial space. In this case, no hemostatic agents of any kind were injected into the pericardial space. Over several minutes, the output, and reaccumulating of blood in the pericardial space slowed, and thus further embolization procedures were deferred. The drain was secured and retained. The patient was admitted to the intensive care unit for conservative management. On post-op day 3, her pericardial drain was removed. Her stay was complicated further by atrial fibrillation with rapid ventricular response, for which she was cardioverted. This was further complicated by a superior cerebellar artery ischemic stroke. She underwent rehabilitation inpatient, and ultimately was discharged on post op day 8 to a skilled nursing facility before returning to her home. One month follow up echocardiogram showed no ongoing pericardial effusion but did show mild to moderate aortic valve regurgitation.

All patients were noted to have severe aortic stenosis and calcifications on the aortic valve, ranging from moderate to severe across all leaflets. Two of the patients had somewhat discordant short and long valve axis measurements, suggesting that perhaps valve sizing may be a factor in annular rupture. The ruptures happened at different times throughout the procedures, suggesting that this is a complication providers should be aware of throughout the procedure. Similarly, for two patients, surgical intervention was strongly considered, but ultimately, conservative management was chosen in patients where the valve was already seated at the time of rupture. Notably, the rupture occurred at different points in the procedures for this patient, in line with the findings of Aminian et al. [13]