TY - JOUR
AU1 - Seese, Laura
AU2 - Schindler, John T
AU3 - Gleason, Thomas G
AU4 - Sultan, Ibrahim
AB - Abstract Transcatheter aortic valve replacement has emerged as a favourable alternative in patients with severe symptomatic aortic stenosis who are at intermediate and/or high risk for open aortic valve replacement. While transcatheter aortic valve replacement has been shown to be a safe alternative to surgical aortic valve replacement in those populations, the procedure is not without risks. Transcatheter heart valve migration can occur, albeit rarely, in an acute, subacute and delayed fashion. This complication can have fatal consequences if not managed appropriately. We describe a patient who underwent a transcatheter aortic valve replacement and had evidence of transcatheter heart valve subacute migration into the left ventricular outflow tract. Transcatheter aortic valve replacement, Valves, Endovascular, TAVI INTRODUCTION Transcatheter aortic valve replacement (TAVR) is a less invasive option for patients with severe, symptomatic aortic stenosis and extensive medical comorbidities, making them intermediate-to-high risk for perioperative complications following surgical aortic valve replacement (SAVR) [1]. Although TAVR continues to evolve as a less invasive approach to SAVR, the procedure is not without risks. TAVR heart valve (THV) migration into the left ventricular outflow tract (LVOT) is a life-threatening complication. Most THV migration events occur acutely following deployment due to malpositioning; however, the exceptionally rare event of subacute or delayed THV migration can occur and lead to fatal consequences if unrecognized. Herein, we describe an unusual case of subacute migration of a THV into the LVOT on postoperative Day 1 and was appreciated on a routine screening transthoracic echocardiogram while preparing for discharge from the hospital. CASE REPORT An 86-year-old man with severe symptomatic aortic stenosis was found to be at intermediate risk for SAVR with a Society for Thoracic Surgeons Percent Risk of Operative Mortality score of 4.33% and was offered a transfemoral TAVR. Preoperative imaging with 3D computer tomography revealed an annular area of 417 mm2. This was the highest measurement after computed tomography angiography (CTA) measurement by both the operators and a cardiovascular radiologist. A 23-mm SAPIEN 3 prosthesis (Edwards Lifesciences Inc., Irvine, CA, USA) was advanced into the aortic annulus and deployed successfully in an ‘85/15’ positioning (Fig. 1A) with rapid pacing. Intraoperative imaging showed appropriate positioning of the valve relative to the annulus with mean valve gradients of 8 mmHg. Postoperatively, the patient was stable without complaints of new symptoms. A routine echocardiogram on postoperative Day 1 revealed migration of the THV into the LVOT exposing the stenotic native valve and creating a prosthetic valve mean gradient of 40 mmHg (Fig. 1B) as well as the impingement of the THV on the anterior leaflet of the mitral valve causing severe mitral regurgitation. The patient subsequently underwent open-heart surgery with retrieval of the migrated valve and an SAVR with a 23-mm St. Jude Trifecta with glide technology (St Paul, MN, USA) valve. Post-surgical mean gradients across the aortic valve were 5 mmHg. The patient was discharged 4 days following SAVR and recovered without complications. Figure 1: View largeDownload slide (A) Intraoperative fluoroscopy following successful transcatheter aortic valve replacement deployments. (B) Preoperative measurement of the annulus. (C) Postoperative transthoracic echocardiogram demonstrating THV migration with exposure of the native stenotic valve. (D) Intraoperative photograph of the THV that migrated into the left ventricular outflow tract. THV: transcatheter aortic valve replacement heart valve. Figure 1: View largeDownload slide (A) Intraoperative fluoroscopy following successful transcatheter aortic valve replacement deployments. (B) Preoperative measurement of the annulus. (C) Postoperative transthoracic echocardiogram demonstrating THV migration with exposure of the native stenotic valve. (D) Intraoperative photograph of the THV that migrated into the left ventricular outflow tract. THV: transcatheter aortic valve replacement heart valve. DISCUSSION An increasing number of patients are treated with TAVR for aortic stenosis. As this population expands, we continue to encounter new presentations of the complications associated with THVs [2]. To our knowledge, this is the first report of subacute migration of a THV. Computational fluid dynamics has demonstrated that significant retrograde pressure acts on the closed THV during diastole [3]. Valvular migration is thought to occur when retrograde forces overcome the strength of the THV’s attachment to the aortic wall. Along these lines, there are 2 complementary hypotheses to describe why THV migration ultimately occurs. The first is malpositioning of the THV inferior to the annulus, leading to poor apposition to the aortic wall, and the second is inadequate or asymmetric degenerative calcific burden, leading to reduced anchoring capacity for the valve stents. It is possible that we may have underestimated the annular size via CTA but as is routine at our centre, measurements were performed by both operators independently, after which we all came to the same conclusion for valve size. The 2 options for correction following THV migration include traditional SAVR with the removal of the migrated valve and a valve-in-valve approach to stabilize the migrating valve with transapical or balloon retrieval. Several small case reports have described successful stabilization and capture of the THV following acute migration during the initial TAVR procedure [4]. Because the patient was only deemed to be at intermediate risk for SAVR, we decided that the safest approach for correction of all aspects of his new pathology would be a standard SAVR with concomitant removal of the THV (Fig. 1C). THV migration into the LVOT is a rare event; however, these patients typically require surgical repair with either TAVR valve-in-valve stabilization and transapical extraction of the migrated valve or traditional SAVR. We were confident in the sizing and the correct coaxial placement of the valve, but the presence of non-uniform calcifications, with heavily calcified left and right coronary cusps and minimally calcified non-coronary cusps, may have reduced the anchoring of the valve stents, predisposing the THV to migrate (Fig. 1D). We may have been able to use a 26-mm THV but would have placed the patient at risk for annular rupture because of prominent LVOT calcification. As indications for TAVR continue to expand to low-risk patient populations with less calcium burden, we anticipate an increase in the incidence of THV migration due to equivalent shear forces acting on the THV without the stabilization that symmetric calcification provides [5]. As such, we must maintain our awareness of THV migration in the operating room and into the perioperative period to ensure that if these events occur, they are captured and corrected expediently to limit adverse sequelae. Conflict of interest: none declared. REFERENCES 1 Reardon MJ , Van Mieghem NM , Popma JJ , Kleiman NS , Sondergaard L , Mumtaz M et al. Surgical or transcatheter aortic valve replacement in intermediate risk patients . N Engl J Med 2017 ; 376 : 1321 – 31 . Google Scholar CrossRef Search ADS PubMed 2 Sultan I , Siki M , Wallen T , Szeto W , Vallabhajosyula P. Management of coronary obstruction following transcatheter aortic valve replacement . J Card Surg 2017 ; 32 : 822 – 5 . Google Scholar CrossRef Search ADS PubMed 3 Dwyer HA , Matthews PB , Azadani A , Jaussaud N , Ge L , Guy TS et al. Computational fluid dynamics simulation of transcatheter aortic valve degeneration . Interact CardioVasc Thorac Surg 2009 ; 9 : 301 – 8 . Google Scholar CrossRef Search ADS PubMed 4 Hachinohe D , Kobayashi K , Furugen A , Koshima R. Left ventricular outflow tract migration of a balloon-expandable prosthesis during transcatheter aortic valve implantation . Int Heart J 2017 ; 58 : 290 – 3 . Google Scholar CrossRef Search ADS PubMed 5 Dwyer HA , Matthews PB , Azadani A , Ge L , Guy TS , Tseng EE. Migration forces of transcatheter aortic valves in patients with noncalcific aortic insufficiency . J Thorac Cardiovasc Surg 2009 ; 138 : 1227 – 33 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
TI - The delayed southern migration of a transcatheter aortic valve
JF - European Journal of Cardio-Thoracic Surgery
DO - 10.1093/ejcts/ezy008
DA - 2018-01-25
UR - https://www.deepdyve.com/lp/oxford-university-press/the-delayed-southern-migration-of-a-transcatheter-aortic-valve-tuztf7YG7j
SP - 1
EP - 188
VL - Advance Article
IS - 1
DP - DeepDyve
ER -