Aortic Laceration During Resheathing of Self-Expanding Valve

Aortic dissection is a serious complication of transcatheter aortic valve implantation (TAVI), with injury by the delivery sheath, delivery catheter, valve implantation, or stent edge being the common cause.¹ We report a case of aortic laceration during TAVI.

A 97-year-old woman was admitted with the diagnosis of a symptomatic bicuspid aortic stenosis and pulmonary hypertension. Considering the presence of a calcified type-1 bicuspid valve (annulus: 90.7 mm, aorta 25 mm above the annulus: 37×37 mm) (Figure A,B), we planned transfemoral TAVI using a 34-mm Evolut PRO+ valve (Medtronic, MN, USA). After predilatation we tried to deploy the valve in a shallow position, but it popped up superiorly (Figure C,D). We retried deployment after resheathing the valve (Figure E, Supplementary Movie), but the patient experienced cardiac tamponade and arrest. We promptly performed pericardiocentesis, and surgically replaced the aortic valve and ascending aorta. Visual inspection revealed a transverse laceration of the aortic intima-media, 25 mm above the annulus, part of which had perforated externally (Figure F,G).

Figure.

Aortic laceration during transcatheter aortic valve implantation. (A) Type 1 bicuspid valve, (B) ascending aorta, (C) predilatation using a 24-mm balloon, (D) popped-up valve at the first attempt, (E) valve resheathing, (F) perforated aorta (arrow), (G) transverse laceration at the inner curvature of the ascending aorta, 25 mm above the annulus (arrows), (H) lower-edge of the 34-mm valve.

The lower edge of the valve stent may have cut the aorta during valve resheathing (Figure H), and aortic vulnerability in a patient with a bicuspid valve may have also contributed to the aortic dissection. We need to be mindful of the distance between the lower valve stent edge and the surrounding structures during valve deployment and resheathing, and slight upward force might be effective while resheathing.

Conflicts of Interest

I.T. is a clinical proctor of TAVI (Edwards Lifesciences and Medtronic). The other authors declare no conflicts of interest.

Supplementary Files

Supplementary Movie. Resheathing of the self-expandable valve.

Please find supplementary file(s);

https://doi.org/10.1253/circj.CJ-23-0167

Reference

• 1.   Hiruma T, Higuchi R, Saji M, Takamisawa I, Shimokawa T, Nanasato M. Transcatheter aortic valve replacement-related aortic dissection: A clinical case series. Catheter Cardiovasc Interv 2023; 101: 668–675.