Atrial Septal Hematoma After Transcatheter Aortic Valve Implantation

An 81-year-old male patient with severe aortic stenosis underwent transcatheter aortic valve implantation (TAVI) because of his high surgical risk (logistic Euro SCORE=17.2%). The average annulus diameter measured by computed tomography (CT) was 23.6 mm (distance: 27.3×21.3 mm, area: 4.38 cm², perimeter: 76.2 mm) (Supplementary Figure 1). Based on facility standards, a 26-mm valve (Edwards Lifesciences, CA, USA) was implanted via the transfemoral approach. Aortic angiography after TAVI did not reveal leakage around the implanted valve, but transthoracic and transesophageal echocardiography revealed a hematoma around the atrial septum (Figure A,B). We immediately reduced the patient’s blood pressure and administered neutralized heparin to prevent the atrial septal hematoma (ASH) from increasing in size. At 1 h later, his hemodynamics remained stable without growth of the ASH, and the operation was terminated. Dual antiplatelet therapy was discontinued just after the operation, and only aspirin was restarted 5 days after because the ASH was decreasing in size (Supplementary Figure 2). The patient was discharged 15 days after TAVI without any other complications. Echocardiography showed the ASH had disappeared 1 month after discharge.

Figure.

(A) The 4-chamber views on transthoracic echocardiography show the atrial septal hematoma (arrowheads). (B) Long-axis views on transesophageal echocardiography show the hematoma (arrowheads). (C) Computed tomography shows a sharp calcification at the bottom of the non-coronary cusp (circled). Ao, aorta; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

To our knowledge, this is the first report of ASH associated with TAVI. In this case, preprocedural CT showed a sharp calcification in the bottom of the non-coronary cusp, which might have damaged the atrial septum, resulting in hematoma formation (Figure C). ASH usually shows no clinical symptoms and resolve spontaneously in 1–3 months. However, in cases of the ASH reaching the atrioventricular node or the epicardium in the acute phase, it may progress to advanced atrioventricular block or cardiac tamponade requiring surgical treatment.¹ TAVI is a wonderful treatment that is less invasive than thoracotomy, but to fully benefit from TAVI, it is necessary to pay close attention to unexpected complications.

Disclosures / IRB Information

None.

Supplementary Files

Please find supplementary file(s);

http://dx.doi.org/10.1253/circj.CJ-20-0276

Reference

• 1.   Miyazaki T, Shiotani H, Kado T, Kazumi T, Matsunaga K, Mizojiri G, et al. Hematoma of the interatrial septum associated with complete atrioventricular block. Jpn Circ J 1990; 54: 636–643.