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Percutaneous Approach With Coil Embolization for Annular Rupture During Transcatheter Aortic Valve Replacement
J INVASIVE CARDIOL 2023;35(6):E323-E324. doi: 10.25270/jic/22.00301
Key words: coil embolization, annular rupture, aortic valve replacement, hemodynamics
A 78-year-old man with symptomatic bicuspid severe aortic stenosis with LVEF 50% was planned for transcatheter aortic valve replacement (TAVR). His CT scan revealed calcified bicuspid aortic valve (Sievers Type 1), calcified raphe with calcium extending up to annulus (Figure 1A). Annulus area was 508 mm2 while left ventricular outflow tract area was 446 mm2.
Aortogram in co-planar view showed calcified annulus with calcified nodule at raphe. Pre-dilatation was done with 20 mm x 50 mm balloon. A 26 mm Edwards Sapiens 3 valve was deployed under rapid pacing.
Hemodynamics were normal and aortogram showed minimal PVL. Immediately, patient became hemodynamically unstable with electromechanical dissociation. Nonselective left main angiogram showed normal flow to left main but annular rupture in the left coronary sinus (Figure 1B, Video 1). Emergent pericardiocentesis started. Annular rupture site was wired with Fielder FC (Asahi Intecc Medical) and Progreat micro-catheter (Terumo). Nester coil (5/70mm, Cook Medical) delivered into the tract.
The angiogram showed no residual leak (Figure 1C). Patient vitals improved and no effusion was seen with 2D-echo. The patient was discharged on day 3.
Annular rupture is a rare but life-threatening complication of TAVR with limited treatment options including conservative management with pericardiocentesis, surgical repair, or second valve implantation. There is a scarcity of data available regarding coil embolization role for annular rupture. Early recognition and timely intervention with coiling/plugs can be definitive treatment modality. Surgical repair carries very high mortality. The above tools and expertise with them should be available in a TAVR center.
Affiliations and Disclosures
From the 1Department of Cardiac Sciences, 2Interventional Cardiology, 3Cardiac Anaesthesia, RHL Heart Center, Rajasthan Hospital, Jaipur, India.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
The authors report that patient consent was provided for publication of the images used herein.
Manuscript accepted October 20, 2022.
Address for correspondence: Ravinder Singh Rao, MD, DM, FACC, Department of Cardiac Sciences, RHL Heart Center, Rajasthan Hospital, Jaipur, India. Email: Rsrao.sn@gmail.com
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