Successful rescue of a "suicide ventricle" during transfemoral transcatheter aortic valve implantation (TF-TAVI)

Abstract

Introduction: Circulatory collapse during transfemoral transcatheter aortic valve implantation (TF-TAVI) procedure is a life-threatening complication. We present an important and poorly described cause. Case report description: An 82 year old male was accepted by the TAVI multi-disciplinary team for TF-TAVI. He had severely impaired left ventricular (LV) function (LVEF 25%), normal LV wall thickness and severe aortic stenosis (PG 63 mmHg, AVA 0.9cm2). Coronary angiography revealed significant disease in the proximal-mid LAD, mid-OM1 and an occluded RCA. His logistic EuroScore was 17.45%. It was felt that since his primary complaint was dyspnoea and he reported no anginal symptoms, in the absence of prognostic coronary disease, he did not require pre-TAVI revascularisation. The procedure was performed under a general anaesthetic with peri-operative tranoesophageal echocardiography (TOE) using a 29 mm Edwards SAPIEN XT with a good final position, no AR and good antegrade haemodynamics. He suffered a rapid loss of blood pressure and ventricular tachycardia, which reverted to asystole after defibrillation. CPR was performed according to guidelines. TOE was used to exclude annular or root injury, iatrogenic disruption of the mitral valve apparatus and prosthesis structural failure or malposition. Angiography confirmed patency of the coronary arteries and ilio-femoral integrity. A suicide ventricle was diagnosed and the decision was made to initiate femoral-femoral cardiopulmonary bypass to stabilise the patient. This was gradually weaned over 30 minutes with successful return of intrinsic cardiac function. Initial post-procedural transthoracic echocardiography demonstrated improvement of LV function (LVEF 45%) with normal prosthetic forward flow and only trivial regurgitation. This echocardiographic improvement was maintained at 60 day follow up with marked symptomatic improvement. Discussion and conclusion: A suicide ventricle is important cause of peri-procedural hypotension and circulatory collapse in TAVI patients. Immediately available fluoroscopic and TOE imaging can help to exclude the other major causes. A perfusionist and a primed CPB machine in the room can allow a desperate situation to be recovered and provide effective bridging for return of myocardial function. The mechanism and aetiology of this difficult complication is not yet known; revascularisation of large areas of at-risk myocardium may be protective. The effects of treatment of coronary artery disease prior to TAVI will be addressed in ongoing the ACTIVATION trial ([ISRCTN75836930][1]). [1]: /external-ref?link_type=ISRCTN&access_num=ISRCTN75836930