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Objectives
Transcatheter aortic valve replacement (TAVR) has become the standard of care for high-risk patients and is growing in popularity for lower risk patients. The authors report a case of early migration of a self-expanding transcatheter aortic valve prosthesis causing coronary obstruction and myocardial infarction.
Methods
A 76-year-old woman with renal failure underwent an uncomplicated TAVR. Thirty-two days later she presented with acute angina, ruled-in for myocardial infarction, and was found to have iatrogenic coronary obstruction from the aortic valve prosthesis due to cephalad migration.
Results
The patient was taken to the operating room where a transverse aortotomy was made at the normal anatomic site (not cephalad to the prosthesis), exposing the metal stent component of the failed device. Multiple attempts at extraction were attempted, however the device was tightly adherent to the left ventricular outflow tract. A 3-0 Prolene suture was weaved through the stent to create a purse string and the suture was snared counteracting the radial force and thus reducing the circumference of the device. The prosthesis was subsequently removed without incident. A surgical aortic valve replacement was then carried out using a 21 mm bovine pericardial bioprosthesis. Cardiopulmonary bypass time was 81 minutes and aortic cross-clamp time was 63 minutes. The patient tolerated the procedure well.
Conclusion
Early migration is a rare complication after TAVR. Self-expanding prosthetic devices may require the use of techniques to counteract the radial forces exhibited on the wall of the left ventricular outflow tract. This report describes a near-lethal early complication and a technique that worked well to facilitate device removal.
This educational video was originally presented during the STSA 65th Annual Meeting. This content is published with the permission of the STSA. For more information on the STSA and its next Annual Meeting, please click here.
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3 Comments
Great video, and very illustrative of a rare complication. Did the authors consider irrigating the prosthesis with cold saline solution? Since nitinol is thermally activated, irrigating the frame with a cold saline solution would cause the stent frame to contract and probably facilitate extraction of the device… Nevertheless, I congratulate the colleagues on their elegant solution in handling this complication.
Would a CABG x2 Off-pump or on-pump-beating heart be an option if no valve malfunction, and +/- tacking suture for the prosthesis to ascending aorta?
Thank you both for your comments. Regarding Dr. Paim’s comment, we are in full agreement that cooling the metal frame theoretically facilitates extraction of the failed prosthesis. We felt that the 4 degree centigrade antegrade and retrograde cardioplegia that was administered prior to opening the aorta would have achieved this goal adequately, without the need for further irrigation.
Regarding Dr. Baslaim’s comments, my main concern with bypassing the left and right coronary systems and tacking the valve in place would be the unpredictable steal from the proximal native coronaries if the prosthesis migrated further up and the coronary ostia were clearly below the valve. With most of the SVG flow feeding the coronaries in diastole, the proximal segments of the coronaries would only see diastolic LV pressures during SVG perfusion and would most likely steal most of the SVG coronary flow. Similar extra-anatomic solutions used in extreme cases of supracoronary aortic valve placement with no native ostial compromise should always be accompanied by native ostia surgical closure (unless the grafts are placed because only a partial coronary occlusion is assumed – such as in a coronary ostium in close proximity to the valve annulus), which may not be feasible through the metal frame of the TAVR prosthesis.
Additionally, ‘tacking’ of the prosthesis blind through the aorta with sutures is probably unpredictable at best.
Unfortunately, surgeons will need to become creative and think “out of the box” when it comes to dealing with these new problems.
I appreciate your comments.
George Tolis, Jr. MD
Cardiac Surgery
Massachusetts General Hospital
Boston, MA