TEVAR with a bare metal stent-graft to rescue embolized transcatheter aortic valve replacements (TAVRs): a report of three cases
Sergio Sastriques, David Dexter, Jean Panneton, Patrick Sowa
EVMS, Norfolk, VA
Background: Embolization of TAVR during placement is a rare complication of the procedure, with rates estimated to be between 0.3 and 1.1%. While there are no guidelines, the most commonly reported management is to reposition the valve into the descending thoracic aorta and fully deploy it as "endotrash". However, this is not always possible if the device has already been fully deployed and is trapped in the ascending aorta or the arch usually because of aortic diameter mismatch. Methods: In this report, we describe 3 patients who underwent TAVR placement complicated by embolization of the valve, all who developed symptoms due to the embolized valve. All were treated by TEVAR using a Cook distal component dissection bare metal stent.Results: The first patient underwent placement of a Sapien XT valve. During placement, pacing wires lost capture and the valve embolized into the ascending aorta. It could not be drawn back due the shape of the aorta, nor could it be fully opposed to the aortic wall. A bioptome was used to grasp the valve and keep it stationary while the stent-graft was deployed in the ascending aorta. The patient recovered neurologically intact and was discharged on post-procedure day 37.
The second patient underwent successful Navitor TAVR placement. Immediately after extubation, he developed respiratory failure leading to cardiac arrest. CPR was initiated. TEE demonstrated embolization of the TAVR from CPR. Resuscitation was initially unsuccessful and he required VA ECMO followed by TandemHeart cannulation. This allowed for new Sapien TAVR to be placed. Due to the location of the embolized valve, the coronaries were not adequately filling. Therefore, TEVAR was deployed in the ascending aorta to exclude the leaflets and allow sufficient diastolic filling of the coronaries. The patient slowly recovered and underwent surgical LVAD placement on post-procedure day 9. During this operation, the TEVAR and leaflets from the embolized TAVR were removed. He suffered multiple complications and was placed on comfort care, ultimately expiring on post-procedure days 22.
The final patient presented in a delayed fashion. He had undergone TAVR procedure seven years prior to presentation. During his index case, the initial Evolut valve embolized and was successfully repositioned into the distal arch just distal to the left subclavian. Second Evolut valve was successfully placed. Seven years later he had developed outflow obstruction and severe heart failure due to the stenosis of the embolized valve. TEVAR was placed through the valve across the arch. However, his clinical condition deteriorated, and he was transitioned to comfort care. He expired on post-procedure day 8.
Conclusions: Each procedure was technically successful, with stabilization of the embolized valve leaflets resulting in appropriate antegrade flow. This report demonstrates that TEVAR with a distal component dissection bare metal stent is an effective bailout technique for an embolized valve after TAVR.
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