Transapical transcatheter aortic valve implantation in a patient with small body weight complicated by severe hypotension: An enigma successfully solved by echocardiography

Abstract

Introduction. Transcatheter aortic valve implantation is currently considered an alternative treatment for older patients with severe aortic valve stenosis and increased surgical risk, but can be associated with multiple life-threatening complications. Case outline. An 83-year-old woman with severe symptomatic aortic stenosis, body weight of 29 kg and body surface area of 1.1 m2 underwent transcatheter aortic valve implantation via transapical access. Severe hypotension occurred before the valve implantation, due to temporary distortion of the mitral valve apparatus by stiff wire, leading to acute mitral regurgitation. This complication was immediately recognized by continuous transesophageal echocardiography and managed by simple wire retrieval instead of applying mechanical circulatory support. After rewiring and predilatation of the stenotic aortic valve, a 23 mm balloon-expandable transcatheter stent-prosthetic valve was successfully implanted. Conclusion. This case demonstrates that continuous imaging during transcatheter aortic valve implantation is key to rapid diagnosis of life-threatening complications, associated with the procedure, especially during the early learning curve in transapical approach.