Transcatheter Aortic Valve Replacement Related Thrombosis in a Patient with a Left Ventricular Assist Device

Abstract

Introduction Transcatheter aortic valve replacement (TAVR) has been reported as treatment for LVAD related aortic insufficiency (AI). However, the risks of this procedure with unique LVAD physiology are not known. This case describes the diagnostic challenges and catastrophic consequences of TAVR related thrombosis in a continuous flow LVAD patient. Case Report A 68 year old male with a history of TAVR, ischemic cardiomyopathy, and VT underwent LVAD implantation as a bridge to decision. The post-op course was complicated by recurrent heart failure and severe LVAD related AI. He underwent valve-in-valve TAVR for LVAD related AI and initial aortography revealed unobstructed flow into the coronary arteries. He developed incessant VT and shock post-operatively. After failure of medical and ablative therapies, he was transferred to our institution for urgent transplant evaluation. He was listed as status 1 for heart transplantation according to current guidelines for life-threatening ventricular arrhythmia. Imaging studies did not raise suspicion for valve related complication. Admission TTE demonstrated moderate RV dysfunction and the TAVR was not well visualized, but it was well seated without regurgitation. Perioperative TEE had limited TAVR evaluation (Figure 1A-B) but there was normal flow across the inflow and outflow cannulas of the LVAD. There was no echo derived aortic valve gradients to cause clinical suspicion for TAVR thrombosis with ischemic complications, so 4D CTA was not obtained. At the time of heart transplantation, the patient was found to have a large aortic root thrombus with extension into the left main coronary artery and a large thrombus extending from the undersurface of the valve causing complete obstruction of the left ventricular outflow tract (Figure 2A-B). Summary We highlight a case of valve-in-valve TAVR related thrombosis as an unexpected cause of VT in LVAD supported patient. Valve thrombosis was not suspected with the available imaging and likely caused the patient's clinical deterioration. The risk of TAVR related complications may be increased in the setting of continuous flow LVAD physiology due to unique flow dynamics and the presence of intermittent or persistent aortic valve closure.