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Journal of Cardiology Cases 9 (2014) 148–150

Contents lists available at www.sciencedirect.com

Journal of Cardiology Cases

j ourna l h omepa ge: www.elsev ier .com/ locate / j ccase

ase Report

nfraannular dislocation and its successful management: rare complication following TAVI

. Hakan Tas (MD), Yavuzer Koza (MD) ∗, Ziya Simsek (MD)taturk University, Faculty of Medicine, Department of Cardiology, Erzurum 25100, Turkey

r t i c l e i n f o

rticle history:eceived 8 October 2013eceived in revised form4 November 2013ccepted 17 December 2013

a b s t r a c t

Transcatheter aortic valve implantation has been increasingly used in symptomatic patients with severeaortic stenosis who are inoperable or at high risk. However it remains associated with the potentialfor serious complications. We report a case in which an Edwards Sapien (Edwards, Irvine, CA, USA)valve prosthesis dislocated to the left ventricular outflow tract with hemodynamic collapse 6 h following

eywords:ortic stenosisranscatheter aortic valve implantationislocation

implantation.<Learning objective: Transcatheter aortic valve implantation (TAVI) is an alternative method to surgicalaortic valve replacement in patients with severe aortic stenosis and high surgical risk. Despite continuousimprovements in operators’ expertise and device technology, it remains associated with the potential forserious complications such as valve dislocation. Dislocation after TAVI is a life-threatening complicationthat requires immediate diagnosis and treatment.>

3 Jap

© 201

ntroduction

Transcatheter aortic valve implantation (TAVI) is now consid-red to be a therapeutic option for patients with severe aortictenosis (AS) who are inoperable or at high risk for conventionalortic valve surgery [1]. It was first described in 2002 by Cribiert al. [2]. Although the procedure has a >95% success rate, it remainsssociated with life-threatening complications different from con-entional aortic valve surgery and different from other catheterrocedures such as dislocation, valve embolization, stroke, perfo-ation of the aorta, and the obstruction of coronary ostia. Theseomplications are also difficult to control in contrast to conven-ional surgery [3,4].

ase report

A 79-year-old man presented with exertional dyspnea andnown severe AS that was refused for surgery in the past. Hisast medical history included coronary artery bypass grafting [left

nternal mammary artery (LIMA) to the left anterior descending

rtery (LAD) and saphenous vein grafts to diagonal and right coro-ary arteries], hypertension, and diabetes mellitus type 2. Overhe preceding 3 months he had been complaining of worsening

∗ Corresponding author at: Ataturk University, Faculty of Medicine, Departmentf Cardiology, Yakutiye, Erzurum 25100, Turkey. Tel.: +90 4422318521;ax: +90 4422361301.

E-mail address: yavuzerkoza@hotmail.com (Y. Koza).

878-5409/$ – see front matter © 2013 Japanese College of Cardiology. Published by Elsettp://dx.doi.org/10.1016/j.jccase.2013.12.007

anese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

dyspnea and dizziness and was becoming increasingly functionallyincapacitated. His New York Heart Association (NYHA) functionalclass was 3. Transthoracic echocardiography (TTE) demonstrateda severe calcified AS with a valve area 0.6 cm2, mean gradient45 mmHg, and left ventricular ejection fraction (LVEF) 30%. The aor-tic annulus was 23 mm. On transesophageal echocardiogram (TEE),the aortic valve leaflets appeared thickened and calcified with mildaortic regurgitation. Society of Thoracic Surgeons (STS) and logisticEuroSCORE were calculated and found to be, respectively, 12 and35%. The risk of conventional surgery was deemed too high and inaccordance with the cardiac surgeon, a transfemoral approach TAVIwith the implantation of a 26 mm Edwards Sapien (ES) (EdwardsLifesciences, Irvine, CA, USA) valve prosthesis was planned.

At coronary angiography, all bypass grafts were patent. Afterinformed consent was obtained and all preventive measures weretaken, the TAVI procedure was performed in the hybrid operatingroom under general anesthesia. After the balloon valvuloplastywas carried out under rapid pacing (Fig. 1, Video 1) a 26 mm ESaortic valve was successfully implanted percutaneously throughthe left femoral artery. Completion aortic root angiogram showedmild paravalvular leak and fine seating of the valve (Fig. 2, Video2). The patient became severely hypotensive 6 h after the pro-cedure and developed ventricular fibrillation. Cardiopulmonaryresuscitation was performed. TTE and aortography demonstrateda dislocated aortic prosthesis into the LVOT (Fig. 3, Videos 3 and

4). The patient was urgently operated and the prosthesis valvewas removed through the native aortic valve (Fig. 4). The nativeaortic valve was mildly calcified and thickened with commissuralfusion. After the complete resection of the native aortic valve, the

vier Ltd. All rights reserved.

M.H. Tas et al. / Journal of Cardiology Cases 9 (2014) 148–150 149

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Fig. 1. Aortic valvuloplasty.

ortic annulus was measured as 21 mm. Surgery was successfullyompleted with the implantation of a metallic prosthetic valvend the patient was discharged from the hospital on the seventhay.

iscussion

Although rare, dislocation occurring after TAVI is a seriousomplication and operators must be prepared for it during TAVIrocedures. Dislocation may emerge in any implantation approach,

ncluding transfemoral, subclavian, and transapical [4]. It can beeen as 3 different types: infra-annularly (intraventricular), supra-nnularly, and supra-sinutubular junction (dislocation into thescending aorta) [5]. A completely implanted dislocated ES pros-hesis can be retracted into the ascending or descending aorta with

gooseneck catheter, and a second valve can be implanted in thennular position. As in our case and some others, retrieval of therosthesis is impossible. This complication may only be treatedurgically [3,4]. Dislocation is usually caused by initial positioningrror and utilizing an undersized valve [6]. Therefore, precise annu-us measurements by echocardiography and if necessary computedomography (CT) are essential [4]. Our measurements were mainlyased on echocardiography. However, the values of the aortic annu-

us diameter vary significantly in different CT and TEE assessmentsnd this matter can be associated with valve dislocation. Indeed,

t has been well recognized that TTE routinely underestimates therue annulus diameter compared to TEE or CT [7]. In this case wexperienced a rare but possible complication of TAVI, although theecommended procedural managements were applied. In our case,

Fig. 2. Aortography after valve deployment showing fine seating of the valve.

inadequate calcification to allow the valve to adhere properly mightbe responsible for valve dislocation. Recently, there have been twocase reports that described second valve implantation for the treat-ment of core valve dislocation [5]. Because it does not work, whenthe ES valve prosthesis is embolized into LVOT or ventricle, espe-cially in hemodynamically compromised patients an attempt topull the prosthesis for implantation of a second prosthesis is some-times impossible. Therefore, the patient was taken directly to theoperating room.

The ES prosthetic valve is usually malpositioned supra-annularly, while embolization, coronary obstruction, and sub-annular positioning are uncommon [4,6]. For prevention of thiscomplication, appropriate imaging of the aortic root with angiogra-phy, TEE, and CT should be performed, with particular attention tothe size and shape of the annulus, as well as the location and distri-bution of any calcification [8]. Other factors that may contribute tomalposition such as suboptimal visualization, lack of burst pacing,poor timing of balloon inflation, lack of predilatation, and interfer-ence from cardiac structures should also be eliminated [6]. As theES prosthesis system is balloon expandable and not repositionableonce expanded, the exact location of deployment must be resolvedand performed in an accurate and careful manner.

Management of infra-annular dislocation depends mainly onthe degree of dislocation and hemodynamic compromise. Deploy-ment of a second overlapping prosthesis may be effective althoughcorrect positioning may be difficult. If the prosthesis is low in theleft ventricular outflow tract, it may not be possible to manage it

with a second overlapping prosthesis and conversion to conven-tional surgery may be the only option [6].

150 M.H. Tas et al. / Journal of Cardiolo

Fig. 3. Aortography showing the dislocated valve into the left ventricular outflowtract.

Fig. 4. The extracted valve.

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gy Cases 9 (2014) 148–150

Conclusion

TAVI is an alternative or promising treatment option withspecific procedure- and patient-related complications. Althoughdislocation of ES prosthesis can be managed interventionally inmost cases, surgical intervention is inevitable in some cases.The procedure must be performed in experienced centers withmeticulous diagnostic evaluation to prevent life-threatening com-plications.

Conflict of interest

None.

Appendix A. Supplementary data

Supplementary data associated with this article can befound, in the online version, at http://dx.doi.org/10.1016/j.jccase.2013.12.007.

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