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Aborted TAVR Following Aortic Balloon Valvuloplasty Khaled D. Algarni, M.D.,* Kevin L. Greason, M.D.,* Rakesh M. Suri, M.D.,* Hector I. Michelena, M.D.,y and Joseph F. Maalouf, M.D.y *Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota; and yDivision of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota ABSTRACT An 80-year-old man with symptomatic severe aortic valve stenosis was referred for transcatheter aortic valve replacement (TAVR) after balloon aortic valvuloplasty (BAV). The TAVR procedure was aborted because of identification of a mobile mass attached to the leading edge of the right cusp of the aortic valve on a transesophageal echocardiography. Surgical aortic valve replacement (SAVR) was performed and this mass was found to be an aortic cusp fenestration rupture that was caused by the BAV. doi: 10.1111/

jocs.12451 (J Card Surg 2015;30:251–252) The use of balloon aortic valvuloplasty (BAV) was initially proposed and generally limited as an alternative to surgical aortic valve replacement (SAVR) in elderly and/or high-risk patients with symptomatic severe aortic stenosis.1 There are currently few data about the potential role of BAV in the era of transcatheter aortic valve replacement (TAVR).2,3 PATIENT PROFILE Report of this case was approved by our Institutional Review Board. An 80-year-old male with severe symptomatic aortic stenosis and two previous coronary artery bypass grafting (CABG) procedures (STS mortality ¼ 8.8%) was evaluated for TAVR. As part of that evaluation, the patient received BAV. Transesophageal echocardiogram was done immediately prior to the valvuloplasty procedure. Examination showed that the aortic valve cusps were thickened with reduced mobility. There were no other abnormalities noted and no masses attached to the cusps. The patient tolerated the valvuloplasty without apparent complication. Follow-up transthoracic echocardiogram demonstrated no significant hemodynamic improvement in valve function and no valve cusp morphological abnormality. Subsequent computed tomography (CT) examination of the aortic valve showed the left ventricular outflow tract area measured 560 mm2 with no other aortic

valve abnormality. The patient was referred for TAVR. Transthoracic echocardiography confirmed severe aortic valve stenosis and no other valve abnormality. Intraoperative transesophageal echocardiography demonstrated a new finding of a 15 mm  4 mm mobile mass attached to leading edge of the right coronary cusp of the aortic valve (Fig. 1). The mass was consistent with a large cusp fenestration or a giant Lambl’s excrescence, but papillary fibroelastoma, vegetation, thrombus, and myxoma were also included in the differential diagnosis. The TAVR was aborted and the patient was transferred to the recovery unit. The patient underwent subsequent uncomplicated repeat sternotomy and the aortic valve was replaced with a 25 mm Hancock 2 porcine prosthesis (Medtronic, Minneapolis, MN, USA). The aortic valve was tricuspid with severe calcification at the bases of the cusps. A long fenestration was attached to the free margin of the aortic valve right cusp (Fig. 2). Although the mass appeared mobile on echocardiography, it was apparent on gross inspection that the mass was well attached and that the risk of embolization would have been low. Pathologic examination of the excised valve cusp was consistent with a ruptured, large aortic valve fenestration. The patient had an otherwise uneventful hospital course and was discharged home on postoperative day 7.

DISCUSSION Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Kevin L. Greason, M.D., Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. Fax: þ1-507-2557378; e-mail: [email protected]

This case demonstrates undiagnosed rupture of an aortic valve fenestration during BAV. Importantly, the abnormality went unnoticed on a CT scan specifically undertaken to assess the aortic valve and 2D transthoracic echocardiograms subsequent to the valvuloplasty.



Figure 1. Two-dimensional transesophageal echocardiogram long-axis view of the aortic valve shows a 15 mm  4 mm mass attached to the leading edge of the right aortic valve cusp.

J CARD SURG 2015;30:251–252

In patients who are considered for TAVR, BAV may be used to palliate those patients with severe congestive heart failure or cardiogenic shock while awaiting screening and work up to be completed. BAV can also serve as a diagnostic method to confirm the potential benefit of TAVR when there is uncertainty whether a patient will benefit from TAVR. Therefore, BAV can identify patients who are too sick and in whom TAVR is considered a futile intervention.2 Those patients usually show no benefit in their symptoms to BAV despite relief of aortic stenosis. This subset of patients who are ‘‘dying with aortic stenosis’’ rather than ‘‘dying from aortic stenosis’’ are not suitable candidate for TAVR and are best palliated with medical treatment.6 In this case report, TAVR was aborted due to a large fenestration—as a result of BAV—that resembled a large vegetation. REFERENCES

Figure 2. Tricuspid calcified aortic valve with mass attached to the leading edge of the right aortic valve cusp. Although the mass appeared mobile on echocardiography, it is apparent on gross inspection that the mass is well attached and that the risk of embolization would have been low.

The finding has an important clinical implication in the relationship between diagnostic or therapeutic BAV and subsequent TAVR. BAV is currently indicated as a bridge to SAVR or TAVR in hemodynamically unstable patients who are at high risk for surgery or in patients with symptomatic severe AS who require urgent noncardiac surgery.4,5

1. Cribier A, Savin T, Saoudi N, et al: Percutaneous transluminal valvuloplasty of acquired aortic stenosis in elderly patients: An alternative to valve replacement? Lancet 1986;1:63–67. 2. Eltchaninoff H, Durand E, Borz B, et al: Balloon aortic valvuloplasty in the era of transcatheter aortic valve replacement: Acute and long-term outcomes. Am Heart J 2014;167:235–240. 3. Ben-Dor I, Maluenda G, Dvir D, et al: Balloon aortic valvuloplasty for severe aortic stenosis as a bridge to transcatheter/surgical aortic valve replacement. Catheter Cardiovasc Interv 2013;82:632–637. 4. Vahanian A, Alfieri O, Andreotti F, et al: Guidelines on the management of valvular heart disease (version 2012): The joint task force on the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2012;33:2451–2496. 5. Nishimura RA, Otto CM, Bonow RO, et al: 2014 AHA/ACC guideline for the management of patients with valvular heart disease: Executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;63:2438–2488. 6. Lindman BR, Alexander KP, O’Gara PT, Afilalo J: Futility, benefit, and transcatheter aortic valve replacement. JACC Cardiovasc Interv 2014;7:707–716.

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Aborted TAVR following aortic balloon valvuloplasty.

An 80-year-old man with symptomatic severe aortic valve stenosis was referred for transcatheter aortic valve replacement (TAVR) after balloon aortic v...
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