547 AN UNUSUAL CONSERVATIVE STRATEGY FOR ACUTE AORTIC RUPTURE AFTER TAVI POST-DILATATION

Abstract

Abstract Transcatheter aortic valve implantation (TAVI) has emerged as an alternative treatment for symptomatic severe aortic stenosis in patients deemed to be at high operative risk for the surgery. Despite its high success, TAVI is associated with rare life-threatening complications. The frequency of aortic annular rupture (AAR) has been reduced by advances in pre-procedural screening and patient selection but, when occurs, often requires emergency surgery with a very high mortality. We described an unusual case managed conservatively. A 86-year-old female patient with NYHA Class III and STS score for mortality of 4.8% underwent TAVI via a transfemoral approach. At preprocedural MDCT the aortic annular area was 293 mm2 with severe calcification of the valve leaflets extending in the outflow tract and in the sinotubular junction with effacement of the coronary sinuses (Fig. 1A-B). Following deployment of a 23-mm self-expanding valve (Medtronic Evolut Pro+) without predilatation, moderate-to-severe residual aortic regurgitation (AR) was observed (Vid. 1). After balloon post-dilatation using a 20×40mm noncompliant (NC) OSYPKA - VACS III balloon, mild-to-moderate AR still persisted (Fig. 1C, Vid. 2). Accordingly, we decided to perform a second post-dilatation using a 22×40mm NC balloon which reduced AR to mild but caused a contained AAR was observed (Fig. D&E, Vid. 3). The patient remained hemodynamically stable with no chest pain and had no pericardial effusion on echo. The risk of a Bentall operation in such a frail elderly patient was judged prohibitive and a conservative strategy was recommended. Postprocedural MDCT confirmed the presence of a pseudoaneurysm with the maximum dimensions of 24×15 mm (Fig. 1F). Patient was followed-up for 23 days first in hospital keeping a low blood pressure with iv nitrates and then in a rehabilitation centre. An MDCT control on day 10 showed no growth of the pseudoaneurysm with a reduction of the brisk filling initially observed. She was discharged without additional problems, and scheduled for a three month control MDCT. Established risk factors for AAR include valve and balloon oversizing, bicuspid valve, small annulus, shallow Valsalva sinuses, and massive annular or sub/supra-annular calcification. When these recognized risk factors are present, a conservative strategy for valve postdilatation is strongly recommended. Early recognition and prompt surgical management of AAR are essential but occasionally also a conserative strategy can prove successful.