An 81-year-old woman undergoes transcatheter aortic valve implantation through femoral access. She was diagnosed with severe calcific aortic stenosis 2 months ago after she began having shortness of breath with mild exertion. The vascular access is gained without complication, and the transcatheter valve is deployed under fluoroscopic guidance. The following hemodynamic changes are observed: Which of the following complications should be suspected in this patient?

Question

An 81-year-old woman undergoes transcatheter aortic valve implantation through femoral access.  She was diagnosed with severe calcific aortic stenosis 2 months ago after she began having shortness of breath with mild exertion.  The vascular access is gained without complication, and the transcatheter valve is deployed under fluoroscopic guidance.  The following hemodynamic changes are observed:  Which of the following complications should be suspected in this patient?

Quizplus · Accepted Answer

11ec160b_3a7a_7d5e_9249_3d9803c0e82c_MD0001_00 The prevalence of severe aortic stenosis (AS) increases with age, and definitive management necessitates surgical correction of the stenotic valve. This often creates a complicated scenario because many elderly patients with severe AS have multiple other comorbidities, making them poor candidates for open surgical valve replacement due to unacceptably high operative risk. Transcatheter aortic valve implantation (TAVI) provides an alternative option for such patients; the catheter is advanced through the aorta to the aortic valve where a bioprosthetic valve is placed over the native aortic valve leaflets. This patient's intraoperative pressure readings of decreased diastolic blood pressure and increased LVEDP (left ventricular end-diastolic pressure) are consistent with aortic regurgitation, a common complication of TAVI that results from improper sealing of the prosthetic valve to the native valve annulus, leading to paravalvular leak (blood leakage around the valve). Inappropriate valve size or improper valve positioning is often responsible. Other intraoperative complications of TAVI include stroke (due to embolization of native valve calcification) and myocardial infarction (due to obstruction of coronary artery ostia by the implanted valve). (Choice B) Worsening mitral stenosis can rarely occur following TAVI; such a disruption is expected to cause a decrease (rather than increase) in LVEDP due to obstructed diastolic filling. (Choice C) Prosthetic valve thrombosis usually causes valvular obstruction but may sometimes cause valvular regurgitation with similar pressure findings to this patient. However, valvular thrombus requires time to develop and is not typically an immediate intraoperative complication. (Choice D) Retroperitoneal bleeding can result from extension of a femoral artery hematoma and is a potential complication of any catheter-based procedure with femoral arterial access. The complication is likely to cause hemorrhagic shock with a drop in both systemic blood pressure and LVEDP. (Choice E) Ventricular septal perforation is a potential complication of TAVI but is unlikely to cause the large and abrupt increase in LVEDP that occurred in this patient. Large perforation may eventually lead to biventricular failure and increased LVEDP, but no change or a small decrease in LVEDP is expected initially. Educational objective: Transcatheter aortic valve implantation (TAVI) allows for minimally invasive management of severe aortic stenosis in elderly patients who are unable to tolerate open surgical valve replacement. Paravalvular aortic regurgitation is a common complication of TAVI, resulting from improper sealing of the prosthetic valve to the native aortic valve annulus. __________ References: Transcatheter aortic valve implantation: technique, complications and perspectives. (http://www.ncbi.nlm.nih.gov/pubmed/25017331)

An 81-Year-Old Woman Undergoes Transcatheter Aortic Valve Implantation Through Femoral