title: Abnormal distortion of aortic corevalve bioprosthesis with suicide left ventricle, aortic insufficiency, and severe mitral regurgitation during transcatheter aortic valve replacement.
abstract: We present a patient with critical degenerative aortic stenosis, mitral annular and aortomitral continuity calcification, and senile sigmoid septal hypertrophy who underwent transcatheter aortic valve replacement using the CoreValve bioprosthesis. Immediately after predilation of the aortic valve (18-mm balloon), the patient developed severe hypotension and dynamic left ventricular outflow tract (LVOT) obstruction with systolic anterior motion of the anterior mitral leaflet, causing severe mitral regurgitation. After deployment of a 26-mm bioprosthesis, a transesophageal echocardiogram and left ventriculogram showed that the frame of the bioprosthesis appeared distorted and underexpanded. On the mitral side of the aorta (side of the aortomitral curtain between 12:00 and 3:00, echo short axis view), we found moderate periprosthetic aortic insufficiency with worse mitral regurgitation. The left ventricle was small and hyperdynamic (ejection fraction >85%). The patient soon developed complete heart block, atrial fibrillation, and ventricular tachycardia. She was resuscitated with aggressive intravenous fluids, vasopressors, and an emergently placed atrioventricular sequential pacemaker. We postdilated the 26-mm bioprosthesis with a 22-mm Z-Med balloon and subsequently with a 25-mm balloon. Each balloon was inflated to its nominal volume and pressure and conformed the nitinol frame of the valve to the net circular shape and expected diameter. However, as soon as each balloon was deflated, the surrounding aortic root anatomy visibly recoiled and the frame returned to its smaller diameter with a distorted shape. A second 26-mm CoreValve bioprosthesis was then deployed in a "valve-in-valve" configuration. Soon after, the patient's hemodynamics improved, her clinical condition stabilized, and she completely recovered. © 2016 Wiley Periodicals, Inc.
authors.affiliation: Center for Heart and Vascular Medicine, Loyola University Medical Center, Maywood, Illinois.
authors.forename: Ferdinand
authors.initials: F
authors.lastname: Leya
authors.affiliation: Center for Heart and Vascular Medicine, Loyola University Medical Center, Maywood, Illinois.
authors.forename: J Michael
authors.initials: JM
authors.lastname: Tuchek
authors.affiliation: Center for Heart and Vascular Medicine, Loyola University Medical Center, Maywood, Illinois.
authors.forename: Walter
authors.initials: W
authors.lastname: Coats
mesh_terms: D001021:Aortic Valve / Q000000981:diagnostic imaging / Q000503:physiopathology; D001022:Aortic Valve Insufficiency / Q000000981:diagnostic imaging / Q000209:etiology* / Q000503:physiopathology / Q000628:therapy; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*; D063126:Balloon Valvuloplasty; D001705:Bioprosthesis; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods; D018618:Echocardiography, Doppler, Color; D017548:Echocardiography, Transesophageal; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods; D006801:Humans; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging / Q000209:etiology* / Q000503:physiopathology / Q000628:therapy; D061330:Multidetector Computed Tomography; D011474:Prosthesis Design; D015641:Radiography, Interventional; D020127:Recovery of Function; D012720:Severity of Illness Index; D013318:Stroke Volume; D016896:Treatment Outcome; D016277:Ventricular Function, Left; D017725:Ventricular Pressure
keywords: aortic annulus; aortic valve disease; elderly patients; mitral annular calcification; sigmoid septum; transcatheter valve implantation