Abstract 2113: Transcatheter Aortic Valve Replacement (TAVR) Complication: Intraoperative Mitral Regurgitation.

Abstract

Introduction: Transcatheter aortic valve replacement (TAVR) is the preferred treatment for aortic stenosis (AS) in patients with high surgical risk. This case report delves into a rare, significant intra-procedural mitral regurgitation (MR) of TAVR. Case Presentation: A 94-year-old female with severe AS and a STS score of 3.9% underwent TAVR. A recent 2D ECHO revealed severe AS. CT angiogram pre-TAVR exhibited scattered coronary artery calcifications, severe aortic valve calcification, and calcified atherosclerotic plaque. During the procedure, a 26mm CoreValve was deployed appropriately, with no perivalvular leak observed on angiography and transesophageal echocardiography (TEE). However, post-deployment, the patient experienced a sudden drop in blood pressure, and intra-procedural TEE revealed severe MR, not detected in previous studies. Treatment included pressors, non-invasive positive pressure ventilation, and diuretics, resulting in a favorable response. Subsequent TTE on the 4th day showed improvement in MR. A one-year follow-up TTE revealed only trace MR, confirming the normal functioning of the prosthetic valve. Discussion: Acute mitral regurgitation is an uncommon TAVR complication with potential morbidity and mortality. Various studies propose multiple mechanisms, and in this case, we attribute it to intraoperative global hypoperfusion causing transient MR. Hypoperfusion of the papillary muscle disrupted leaflet coaptation, leading to MR, as supported by its resolution with improved blood pressure. Studies have reported different mechanisms for acute MR, including papillary muscle rupture, leaflet perforation, guidewire impingement, and global hypoperfusion, with some indicating a higher incidence in CoreValve compared to other valve types. Conclusion: Given the rarity of acute MR during TAVR and the unclear pathophysiology, there are no established society guidelines for its management. With TAVR becoming routine, further clinical trials are crucial for optimizing treatment, including head-to-head comparisons of valves and procedural techniques, and developing comprehensive management strategies based on the specific mechanisms of this acute complication.