Clin Res Cardiol DOI 10.1007/s00392-014-0696-0

CRITICAL PERSPECTIVE

Contained aortic annulus rupture with persisting false aneurysm after transfemoral transcatheter aortic valve implantation Stephanie Egenrieder • Stephan Hill Maik Backes • Matthias Vo¨hringer • Udo Sechtem



Received: 11 February 2014 / Accepted: 27 February 2014 Ó Springer-Verlag Berlin Heidelberg 2014

Abstract With older age and increasing comorbidities, conventional operative procedures for severe symptomatic aortic stenosis are associated with a high surgical risk. To date, transfemoral transcatheter aortic valve implantation (TF-TAVI) represents an accepted alternative method of intervention with a cardiovascular and all-cause mortality similar to operative replacement at early and long-term follow-up in this high risk population (Thomas et al., Circulation 124:425–433, 2011). Despite growing experience of the operators and improvement of the devices procedural and perioperative complications still occur (Panchal et al., Am J Cardiol, 2013). Aortic annulus rupture as well as the rupture of the membranous ventricular septum has been reported (Aminian et al., Catheter Cardiovasc Interv 81:E72–E75, 2013). We present the unusual case of an 80-year-old female who developed a false aneurysm following a contained aortic annulus rupture during a TF-TAVI procedure. Keywords Transfemoral transcatheter aortic valve implantation  Aortic annulus rupture  False aneurysm

S. Egenrieder (&)  S. Hill  U. Sechtem Abteilung fu¨r Kardiologie, Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376 Stuttgart, Germany e-mail: [email protected] M. Backes Institut fu¨r Radiologie, Robert-Bosch-Krankenhaus, Stuttgart, Germany M. Vo¨hringer CCLB Ludwigsburg, Ludwigsburg, Germany

Case An 80-year old female with known protein S-deficiency syndrome, recurrent pulmonary embolism and endocarditis in the past, presented to the emergency department with a history of persisting subfebrile temperatures for several days and progressive exertional dyspnoea. The patient was known to have aortic stenosis. Suspecting endocarditis, a TEE was performed. Vegetations could not be detected and repeatedly drawn blood cultures remained sterile. However, aortic stenosis was found to be severe with a gradient pmax/mean of 118/76 mmHg by transthoracic echocardiography. After interdisciplinary discussion with colleagues from the Department of cardiac and vascular surgery and because of high-surgical risk for valve replacement (STS Score risk of mortality 13 %) the heart team decided to perform a transfemoral transcatheter aortic valve implantation. In the preoperative TEE the annulus diameter was 18 mm; in the multislice CT examination however, the minimum and maximum diameter were 20 and 26 mm, respectively. The average diameter calculated by the annulus perimeter was 24.5 mm. In addition, severe calcification of the annulus and in the left ventricular outflow tract was seen. Based on the results of these preoperative examinations, the heart team decided on the implantation of a 26 mm Edward SAPIEN XT valve. After balloon-pre-dilation of the aortic valve, the new valve was successfully implanted and the intraoperative TEE demonstrated adequate valve function. During the first week after implantation, the patient developed signs of inflammatory disease and a reduction in well-being. Echocardiography was repeated and a new pericardial effusion was detected which had not existed prior to the implantation of the SAPIEN XT valve (Fig. 1). To exclude post-procedural aortic dissection, the patient was followed up by CT.

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Fig. 1 Axial CT of the pericardial effusion (red arrows) after implantation of the TF-TAVI; density values suggest serous fluid mixed with blood

In addition to the pericardial effusion there were two communicating, contrast medium accumulating structures distal of the left main coronary artery (Fig. 2). The new aneurysm like structure extending from the aorta around the left main coronary was interpreted to represent a contained rupture of the aortic annulus (Fig. 3). Facing the high risk of a surgical intervention and because of the fact that the rupture seemed to be contained, it was decided to continue a conservative approach with short term CT follow-up. The pericardial effusion with density values a little higher than serous fluid was interpreted as a post-cardiotomy syndrome. It was treated with steroids and analgesic drugs. In the follow-up examinations after 4 and 6 months, the CT findings were unchanged with respect to the false aneurysm. The pericardial effusion was no longer present. The physical condition of the 80-year-old was good.

Discussion This case demonstrates an uneventful follow-up after a potentially serious post-TAVI complication. The likely cause of the annulus rupture was the implantation of the valve carrying stent into the native valve characterized by spiky and sharp calcifications. The preoperative TEE showed a diameter of the annulus of 18 mm, and the multislice CT showed a diameter of 20 mm in the short axis of the aortic annulus. As the average diameter calculated by the aortic annulus perimeter was 24.5 mm, a 26 mm SAPIEN XT valve was the proper choice. In

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Fig. 2 Axial presentation of the aneurysm like structure (red star) next to LCA (small arrows)

the setting of the severe calcification of the aortic annulus and the LVOT, the eccentricity of the aortic root (20/26 mm) caused a higher risk for the annulus rupture. Blanke et al. had shown in a retrospective study of 72 TAVI patients in which they had performed pre- as well as postoperative CTs, that in patients with relative oversizing of prothesis the rate of contained rupture was significantly higher compared with patients without oversizing [2].

Conclusions A contained annulus rupture with aneurysm formation may have a benign course with conservative management. In order to minimize the risk of an annulus rupture, it might be appropriate to downsize the diameter of the prosthesis in patients with massive calcifications of the aortic root and the LVOT. The use of a valve carried by a selfexpanding nitinol stent would be the alternative which should be considered, if the patient has severe aortic valve calcifications. This valve can be implanted using a smaller balloon, reducing the risk of annulus rupture. However, the incidence of postinterventional paravalvular regurgitation is higher with the nitinol stent valve and postinterventional paravalvular regurgitation is associated with a higher incidence of subsequent death.

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Fig. 3 a Coronal CT before TF-TAVI. No aneurysm like structure is present inferior to the left main stem (small red arrow). b After the TF-TAVI procedure there is an aneurysm-like structure (red star)

inferior to the left main stem (small arrow). Large red arrow shows the connection between aneurysm like structure and the aortic annulus rupture

Conflict of interest The authors declare that they have no conflict of interest. The patient gave informed consent. The manuscript does not contain clinical studies.

aortic valve implantation is associated with contained rupture of the aortic root. Circ CardiovascInterv 5(4):540–548 3. Panchal HB, Ladia V, Desai S, Shah T, Ramu V (2013) A metaanalysis of mortality and major adverse cardiovascular and cerebrovascular events following transcatheter aortic valve implantation versus surgical aortic valve replacement for severe aortic stenosis. Am J Cardiol (published online) 4. Thomas M, Schymik G, Walther T, Himbert D, Lefe`vre T, Treede H, Eggebrecht H, Rubino P, Colombo A, Lange R, Schwarz RR, Wendler O (2011) One-year outcomes of cohort 1 in the Edwards SAPIEN Aortic Bioprosthesis European Outcome (SOURCE) registry: the European registry of transcatheter aortic valve implantation using the Edwards SAPIEN valve. Circulation 124(4):425–433

References 1. Aminian A, Lalmand J, Dolatabadi D (2013) Late contained aortic root rupture and ventricular septal defect after transcatheter aortic valve implantation. Catheter Cardiovasc Interv 81(1):E72–E75 2. Blanke P, Reino¨hl J, Schlensak C, Siepe M, Pache G, Euringer W, Geibel-Zehender A, Bode C, Langer M, Beyersdorf F, Zehender M (2012) Prothesis oversizing in balloon-expandable transcatheter

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Contained aortic annulus rupture with persisting false aneurysm after transfemoral transcatheter aortic valve implantation.

With older age and increasing comorbidities, conventional operative procedures for severe symptomatic aortic stenosis are associated with a high surgi...
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