International Journal of Cardiology 173 (2014) e31–e32
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Balloon valvuloplasty after Transcatheter Aortic Valve Implantation (TAVI): always safe? E. Fabris ⁎, A. Perkan, E. Rauber, A. Pappalardo, A. Salvi, G. Sinagra Cardiovascular Department, “Ospedali Riuniti” and University of Trieste, Trieste, Italy
a r t i c l e
i n f o
Article history: Received 21 January 2014 Accepted 9 March 2014 Available online 18 March 2014 Keywords: TAVI Balloon valvuloplasty Prosthesis dislocation
An 82 year old man was referred to our Center for a severe symptomatic aortic stenosis. Patient was selected by the Heart Team for transcatheter aortic valve implantation (TAVI) because of a high surgical risk (log. EuroSCORE 21%). The diameters of the aortic annulus were 32 × 22 mm, the perimeter was 87 mm. A 31 mm CoreValve™ prosthesis (Medtronic, Minneapolis, MN, USA) was selected. After femoral access with an 18 Fr sheath, a stiff guidewire was placed in the left ventricle and the prosthesis was advanced across the stenotic valve without prior balloon valvuloplasty (BV). The sheath cover was then retracted under fluoroscopic guidance (Fig. 1A, online Video 1) and the valve released. The position of the valve seemed optimal with the distal end of the prosthesis reaching 5 mm into the left ventricular outflow tract (Fig. 1B, online Video 2) but a significant aortic regurgitation (AR) was present and the valve was not completely expanded in its distal part.
⁎ Corresponding author at: Cardiovascular Department, “Ospedali Riuniti” and University of Trieste, Via Valdoni 1, 34149 Trieste, Italy. E-mail address: [email protected] (E. Fabris).
http://dx.doi.org/10.1016/j.ijcard.2014.03.060 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
We decided to perform a BV with a Cristal ballon 28 × 50 (Balt, Montmorency, France). The balloon was advanced over the valve and was inflated during a rapid pacing (Fig. 1C). At angiography, after the deflation of the balloon, the valve showed an appropriate expansion but had moved upwards now with the distal part ending apparently above the angiographic annulus (Fig. 1D, Online video 3). The patient was stable and after repeated angiographic controls the valve seemed anchored without further upward movements. Final angiography showed only a mild AR (Online video 4); systolic gradient was absent and a persistence good result was documented at follow up echo after 2 weeks. Prosthesis dislocation during TAVI is a rare but important complication. BV after valve implantation is principally performed to fully expand the valve or to correct paravalvular AR (1). In the presented case a post implantation BV caused an acute accidental dislocation of CoreValve with potential risk of its embolization. BV after CoreValve implantation performed without a prior dilatation is an effective procedure but it may cause accidental movements of the prosthesis despite a meticulous technique. This may be relevant because the strategy of performing TAVI without balloon predilatation is becoming common. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2014.03.060. Reference [1] Grube E, Naber C, Abizaid A, et al. Feasibility of transcatheter aortic valve implantation without balloon pre-dilation: a pilot study. JACC Cardiovasc Interv 2011;4:751–7.
e32
E. Fabris et al. / International Journal of Cardiology 173 (2014) e31–e32
Fig. 1. A Sheath cover retracting under fluoroscopic guidance. B Result after release of the prosthesis: good placement but compression of the distal part of the prosthesis. C Rapid pacing monitoring during balloon valvuloplasty. D Cranial dislodgement of the prosthesis after balloon valvuloplasty.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Balloon valvuloplasty after Transcatheter Aortic Valve Implantation (TAVI): always safe? E. Fabris ⁎, A. Perkan, E. Rauber, A. Pappalardo, A. Salvi, G. Sinagra Cardiovascular Department, “Ospedali Riuniti” and University of Trieste, Trieste, Italy
a r t i c l e
i n f o
Article history: Received 21 January 2014 Accepted 9 March 2014 Available online 18 March 2014 Keywords: TAVI Balloon valvuloplasty Prosthesis dislocation
An 82 year old man was referred to our Center for a severe symptomatic aortic stenosis. Patient was selected by the Heart Team for transcatheter aortic valve implantation (TAVI) because of a high surgical risk (log. EuroSCORE 21%). The diameters of the aortic annulus were 32 × 22 mm, the perimeter was 87 mm. A 31 mm CoreValve™ prosthesis (Medtronic, Minneapolis, MN, USA) was selected. After femoral access with an 18 Fr sheath, a stiff guidewire was placed in the left ventricle and the prosthesis was advanced across the stenotic valve without prior balloon valvuloplasty (BV). The sheath cover was then retracted under fluoroscopic guidance (Fig. 1A, online Video 1) and the valve released. The position of the valve seemed optimal with the distal end of the prosthesis reaching 5 mm into the left ventricular outflow tract (Fig. 1B, online Video 2) but a significant aortic regurgitation (AR) was present and the valve was not completely expanded in its distal part.
⁎ Corresponding author at: Cardiovascular Department, “Ospedali Riuniti” and University of Trieste, Via Valdoni 1, 34149 Trieste, Italy. E-mail address: [email protected] (E. Fabris).
http://dx.doi.org/10.1016/j.ijcard.2014.03.060 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
We decided to perform a BV with a Cristal ballon 28 × 50 (Balt, Montmorency, France). The balloon was advanced over the valve and was inflated during a rapid pacing (Fig. 1C). At angiography, after the deflation of the balloon, the valve showed an appropriate expansion but had moved upwards now with the distal part ending apparently above the angiographic annulus (Fig. 1D, Online video 3). The patient was stable and after repeated angiographic controls the valve seemed anchored without further upward movements. Final angiography showed only a mild AR (Online video 4); systolic gradient was absent and a persistence good result was documented at follow up echo after 2 weeks. Prosthesis dislocation during TAVI is a rare but important complication. BV after valve implantation is principally performed to fully expand the valve or to correct paravalvular AR (1). In the presented case a post implantation BV caused an acute accidental dislocation of CoreValve with potential risk of its embolization. BV after CoreValve implantation performed without a prior dilatation is an effective procedure but it may cause accidental movements of the prosthesis despite a meticulous technique. This may be relevant because the strategy of performing TAVI without balloon predilatation is becoming common. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2014.03.060. Reference [1] Grube E, Naber C, Abizaid A, et al. Feasibility of transcatheter aortic valve implantation without balloon pre-dilation: a pilot study. JACC Cardiovasc Interv 2011;4:751–7.
e32
E. Fabris et al. / International Journal of Cardiology 173 (2014) e31–e32
Fig. 1. A Sheath cover retracting under fluoroscopic guidance. B Result after release of the prosthesis: good placement but compression of the distal part of the prosthesis. C Rapid pacing monitoring during balloon valvuloplasty. D Cranial dislodgement of the prosthesis after balloon valvuloplasty.
![[Transcatheter aortic valve implantation (TAVI)].](/assets/img/hold.png)
