Rupture of the ascending aorta 6 months after TAVI procedure caused by TAVI prosthesis

Abstract

Background

Transcatheter aortic valve implantation (TAVI) is indicated for elderly patients who often have severe comorbidities and high operative risk. Despite many advantages, it carries the potential for both early and late complications. The literature reports mainly periprocedural problems. This case report describes a rare instance of ascending aortic rupture as a late complication following TAVI.

Case presentation

An 81-year-old male with severe aortic stenosis (AS) was a non-surgical patient due to a high operative risk (EuroSCORE II 14.08%) and comorbidities, including cardiovascular problems, chronic obstructive pulmonary disease, myelodysplastic syndrome. During the TAVI procedure Medtronic CoreValve™ Evolut™ R-26 was implanted via the right femoral artery. Postoperative period elapsed without complications and the patient was discharged home. Six months later, the patient was re-admitted to the hospital on an emergency basis and transferred directly to the operating room due to ascending aortic rupture (EuroSCORE II 53.20%, GERAADA score 64.9%). Computed tomography angiography (CTA) showed aortic rupture with a multiple fresh blood reservoirs and thrombus around the ascending aorta originating from the spot where the nitinol frame of the TAVI valve was attached to the native aorta. Supracoronary excision of the ascending aorta with implantation of a vascular graft (Intergard Woven Graft 34 mm) was performed, preserving the earlier implanted TAVI valve. On the 9th day after surgery the patient’s general condition deteriorated, he suffered from circulatory and respiratory insufficiency. Furthermore, a gastrointestinal bleeding with the need for gastro-, and colonoscopy and multiple blood transfusions occurred. Patient developed urosepsis and acute renal failure with the need for hemodiafiltration. Despite intensive treatment, further deterioration of the medical condition of the patient. and finally the multiple organ failure was observed. Patient died on the 50th postoperative day.

Conclusions

TAVI is a safe method of treating severe AS, especially recommended for non-surgical candidates. Rupture of the ascending aorta is a rare but serious complication of TAVI that usually occur during or shortly after the procedure. This case report highlights the importance of post-procedural monitoring for such TAVI complications, even in the late period following TAVI, and if such complications occur, taking the risk to perform a life-saving operation.

Background

According to the European Association for Cardio-Thoracic Surgery (EACTS) 2021 Guidelines, the TAVI procedure is preferred for patients with a higher surgical risk, advanced age, and severe frailty. A Heart-Team is crucial for the success of a TAVI program. Significant considerations are given to the patient’s overall physical health, any existing medical conditions they may have, as well as the specific vascular and cardiac anatomy pertinent to the case [1].

Currently, there are many TAVI platforms available on the market, supplied by various companies. The most popular are balloon-expandable Edwards Sapien Valve and self-expandable Medtronic CoreValve™ [2].

Although TAVI is a relatively safe procedure, it may also lead to numerous complications, including atrioventricular block, paravalvular leak (PVL), cerebrovascular events, vascular, annular, or ventricular problems, hypoattenuated leaflet thickening and endocarditis [1, 3]. The majority of these complications occur in the periprocedural period, with late complications being very rare with scarce reports in the literature.

Case Presentation

An 81-year-old male patient, 167 cm of height and 61 kg of weight, with severe, symptomatic AS (CCS II, NYHA III) (peak gradient 61 mmHg, mean gradient 35 mmHg, V_max 3,9 m/s) was considered as non-surgical due to high operative risk (EuroSCORE II 14.08%) and comorbidities: tricuspid valve regurgitation with concomitant severe pulmonary hypertension, congestive heart failure (ejection fraction (EF) 25%), hypertension, diffuse atherosclerosis, chronic obstructive pulmonary disease and myelodysplastic syndrome.

Considering the patient’s condition and medical history, the Heart Team decided to perform TAVI instead of surgical aortic valve replacement. In the preoperative computed tomography angiography (CTA), the diameter of the heavily calcified ascending aorta did not exceed 3 cm (Fig. 1). In June 2022, Medtronic CoreValve™ Evolut™ R-26 was successfully implanted via the right femoral artery (Fig. 2). Follow-up echocardiography confirmed no PVL and well-functioning aortic prosthesis (peak gradient 13 mmHg, mean gradient 7,5 mmHg, V_max 1,8 m/s). Postoperative period elapsed without complications and the patient was discharged home on the 3rd post-implantation day.

Fig. 1

Preoperative computed tomography angiography (CTA) of the ascending aorta

Fig. 2

Image of medtronic CoreValve evolut R-26 after implantation via the right femoral artery

In December 2022, 6 months after TAVI, the patient fainted at home. After regaining consciousness, he reported acute pain in the chest, dyspnoea, exhibited slurred speech and body tremors, which persisted until admitting to the hospital. The patient developed haemorrhagic shock. CTA of the aorta revealed a fresh blood reservoir around the nitinol frame of the TAVI valve − 40 mm x 32 mm on the posterior side of the aorta, and 35 mm x 23 mm on the left side of the aorta. In the pericardium, a thick-walled reservoir containing fresh blood (52 × 53 mm) was visible. The patient was diagnosed with acute ascending aortic rupture (Fig. 3). His EuroSCORE II was 53.20% and GERAADA score reached 64.9%. After assessment by the Heart Team and thorough explanation to the patient and patient’s family about severity of the clinical situation and extreme risks involved with the surgery, the consent for surgical approach was provided.

Fig. 3

CT image and 3D image reconstruction of ascending aortic rupture

Intraoperatively, 3 intimal tears and rupture of the ascending aorta were found, probably in relation to the contact between the nitinol frame of the implanted valve and the aortic wall. During the procedure ascending aorta was replaced with an Intergard Woven Graft 34 mm. The proximal anastomosis was made at the level of the sinotubular junction, just above the coronary ostia. Distal anastomosis was performed at the point in the upper part of the ascending aorta before the beginning of the aortic arch. The nitinol frame of the TAVI valve was preserved by carefully aligning the graft with the edges of the TAVI cage and tightly suturing it to ensure structural integrity and functionality of the valve. The TAVI valve function was preserved therefore aortic valve replacement was not performed. Additionally, an injury of the anterior mitral leaflet, an aneurysm, was observed (Fig. 4); however, it had no influence on mitral valve competency.

Fig. 4

Echocardiography image - aneurysm of the anterior mitral leaflet due to mechanical injury probably caused by the nitinol frame of the implanted valve

Haemostasis was very challenging, and the sternum closure was postponed. After successful sternal closure on the next day the patient was quickly extubated and transferred to the regular ward. In the early phase of the postoperative course the patient started active rehabilitation. He was able to walk down the hall on his own. However, because of his general frailty, an unexpected gradual deterioration of the patient’s general condition was observed. He developed a sternal wound infection, which required targeted antibiotic therapy, treatment with vacuum-assisted device and ultimately rewiring of the sternum. In the further postoperative course, left-sided haemothorax occurred, with the need for surgical treatment via left mini-thoracotomy. The patient developed gastrointestinal bleeding despite having been on proton-pump inhibitor. Urosepsis developed. The urine culture, blood culture and bronchoalveolar lavage tests were positive for Klebsiella pneumoniae. The patients’ condition worsened and he required aggressive mechanical ventilation with high oxygen concentration and high positive end-expiratory pressure. Patient’s haemodynamics was supported by noradrenaline and acute kidney injury required hemofiltration.

On the 50th postoperative day due to multi-organ failure, irreversible septic shock, and cardiac arrest, the patient passed away.

Discussion and conclusions

Although TAVI is a relatively safe procedure, potential complications including the possibility of their occurrence long after the operation are possible.

Lange et al. in an analysis of 412 patients undergoing TAVI between 2007 and 2010 reported that only 2 of these patients experienced delayed rupture of the ascending aorta [4].

The rupture of the aorta is a very rare complication after TAVI (< 1%), but it is a life-threatening condition. It results in a swiftly advancing haemorrhagic shock. Despite immediately performed medical procedures, mortality rate remains considerable [5].

Also, an aortic dissection occurs very rarely after TAVI procedure, with high mortality and reported incidence between 0.6% and 1.9% [6, 7].

In this case, a self-expandable Medtronic CoreValve™ was chosen, which may give a higher risk of aortic rupture due to continuous outward radial force. Balloon-expandable TAVI devices, such as Edwards Sapien Valve, theoretically carry a lower risk of rupture due to one-time radial expansion that reduces mechanical stress on the aortic wall. This may reduce this type of complications. On the other hand, balloon-expandable TAVI devices may pose a bigger risk of other complications, such as annular rupture as a result of overdilatation [8]. Annular rupture is a very rare TAVI complication (1%) and includes periprocedural injuries in the region of the aortic root and left ventricular outflow tract. This complication, although rare, can be potentially fatal if not recognized and managed promptly. It should be treated surgically as soon as possible [8].

The most probable mechanism of anterior mitral leaflet aneurysm formation appears to be mechanical injury caused by the nitinol frame of the implanted TAVI valve. Specifically, lower implantation of the TAVI valve could have led to excessive contact between the nitinol frame and the anterior mitral leaflet, resulting in structural damage and the formation of an aneurysm in the leaflet.

This case highlights the critical importance of careful post-procedural monitoring for TAVI complications, such as aortic rupture, even in the late period following TAVI.

Immediate surgical intervention is often the only possible treatment option. The decision to operate was crucial to attempt to save the patient’s life despite the risk associated with the procedure.