title: Annular rupture leading to fatal complications in an elderly patient with calcified aortic and mitral annulus undergoing transapical aortic valve implantation.
abstract: This case illustrates the awareness that must be taken of the high morphological risk due to the calcifications of both, the aortic and mitral annulus in elderly patients when performing transapical aortic valve implantation. In an 86-year-old, multimorbid woman (logistic EuroSCORE = 27%) with symptomatic aortic stenosis (annular diameter = 23.4 mm) and severe mitral annular calcification, the implantation of a 26-mm Edwards SAPIEN (Edwards Lifesciences, Irvine, California, United States) valve in aortic position was primary successful, with no paravalvular leakage, valve instability, or coronary malperfusion. Second, a persisting transmural bleeding led to hypovolemic shock, which could not be stabilized even after going on cardiopulmonary bypass, and the patient died in the operation room. The autopsy showed a subvalvular ventricular rupture due to a transmural perforation of the calcified fibrotic annulus during valvuloplasty.
authors.affiliation: Cardiothoracic Surgery, Ruhr-University of Bochum, Germany. haldenwangpeter@hotmail.com
authors.forename: Peter L
authors.initials: PL
authors.lastname: Haldenwang
authors.forename: Matthias
authors.initials: M
authors.lastname: Bechtel
authors.forename: Markus
authors.initials: M
authors.lastname: Schlömicher
authors.forename: Michael
authors.initials: M
authors.lastname: Lindstaedt
authors.forename: Justus T
authors.initials: JT
authors.lastname: Strauch
mesh_terms: D000369:Aged, 80 and over; D001021:Aortic Valve / Q000473:pathology*; D001024:Aortic Valve Stenosis / Q000150:complications / Q000175:diagnosis / Q000628:therapy*; D001027:Aortography / Q000379:methods; D001344:Autopsy; D063126:Balloon Valvuloplasty / Q000009:adverse effects*; D002114:Calcinosis / Q000150:complications / Q000175:diagnosis / Q000628:therapy*; D006328:Cardiac Catheterization / Q000009:adverse effects* / Q000295:instrumentation; D017809:Fatal Outcome; D005260:Female; D006341:Heart Rupture / Q000209:etiology*; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects* / Q000295:instrumentation / Q000379:methods; D006470:Hemorrhage / Q000209:etiology; D006801:Humans; D008943:Mitral Valve / Q000000981:diagnostic imaging / Q000473:pathology*; D011474:Prosthesis Design; D012769:Shock / Q000209:etiology; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome