Takashi Ota

CASE

An 84-year-old woman. Transcatheter aortic valve implantation (TAVI) was planned with a femoral approach to severe aortic valve stenosis.

Pre-operative transthoracic echocardiogram (TTE) found significant left ventricular hypertrophy, and coronary angiography (CAG) revealed stenotic lesion at left anterior descending artery. The ischemic lesion was treated by percutaneous coronary intervention previous to the TAVI operation.

The TAVI operation was done under local anesthesia with sedation, and there were no abnormalities of vital signs during the operation. The intra-operative TTE found no significant pericardial effusion or wall motion abnormality, and the paravalvular leakage.

After the operation was completed, she was moved to the ICU.

However, after a few hours stay at the ICU, she became restless, and fell into cardiopulmonary arrest. The ICU-bedside TTE found a narrow left ventricular cavity, a small amount of pericardial effusion and a low echo area at ​​the left ventricular anterior wall.

While continuing the resuscitation, we moved her to the catheter laboratory immediately and percutaneous cardio-pulmonary support and intra-aortic balloon pumping were started.

Emergency CAG was performed but it was same as with preoperative evaluation. As a drainage to the pericardial effusion was performed, some reddish blood was caught. Accompanied with these finding, we suspected of cardiac tamponade due to ventricular perforation and made consultation to cardiac surgeons to repair.

When the pericardium was opened on the cardiopulmonary bypass, a perforation; considered to be damaged due to a guide wire during TAVI operation, was found on the anterior wall of the left ventricle. After the surgically repair, she returned to the ICU.

DISCUSSION

Echocardiographic evaluation plays an important role in the hemodynamic insufficiency.

Especially in patients with TAVI, it is necessary to distinguish between the cardiac tamponade caused by the rupture of aortic root and Suicidal Left Ventricle; a pathological condition due to an afterload decreasing.

In this case, it was difficult to distinguish that because it developed slowly. According to the ICU-bedside TTE and the CAG findings, finally, we could make the diagnosis and preferable patient management.

CONCLUSION

Although a delayed occurring ventricular perforation is rare, it needs to be considered in the observation period at ICU. Echocardiography plays an important role of evaluation in the hemodynamic insufficiency and perioperative complications of TAVI.