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Echo Rounds

Echo Case

Norbert J. Rios, MD1; Mark Nelson2; Vigneshwar Kasirajan3

  1. Cardiothoracic anesthesia fellow, Department of Anesthesia, Virginia Commonwealth University, Richmond, VA
  2. Assistant professor, Department of Anesthesia, Virginia Commonwealth University, Richmond, VA
  3. Chairman of surgery, Virginia Commonwealth University, Richmond, VA

We present a case in which a transcatheter aortic valve replacement (TAVR) was undertaken for aortic stenosis (AS) (video 1) during an on-pump coronary artery bypass grafting (CABG). Following the CABG and while still on cardiopulmonary bypass (CPB), an aortotomy was performed and under direct visualization a 26 mm Edwards second-generation SAPIEN valve was deployed in the aortic position utilizing themanufacturer’s balloon inflation specifications. During weaning from CPB, a perivalvular leak was discovered (video 2). After resumption of CPB and repeat aortotomy, the prosthetic valve was found to be freely mobile within the aortic annulus. Surgical aortic valve replacement (SAVR) was subsequently performed and the patient’s remaining hospital course was unremarkable and doing well at home.

The reasons to replace the aortic valve in this fashion were: reduced duration of CPB, better hemodynamic profile achieved with a TAVR vs. SAVR, and suitability for implantation in highly calcified annuluses, as was the case with our patient. Possible etiologies for the prosthesis mobility and perivalvular leak include expansion of the annulus after rewarming and resumption of cardiac function.

A cool and arrested heart may have a functionally smaller annulus or may have increased resistance to deploying (balloon) forces required for successful valve implantation. The possibility of utilizing increased (beyond manufacturer’s recommendations) balloon pressure was discussed after the TAVR failure but was decided against in favor for SAVR.

Videos

Questions

  1. What grade would you classify this TAVR perivalvular leak?
    1. Mild
    2. Moderate
    3. Moderate to severe
    4. Severe
    5. Unable to quantify
  2. What are the benefits of TAVR over SAVR?
    1. Lower prosthesis-patient mismatch 
    2. Increased indexed effective orifice area (EOA)
    3. Decreased transvalvular gradients
    4. All of the above
Mindray Anesthesia Workstation