Successful Urgent Alcohol Septal Ablation for Hemodynamic Collapse Following Transcatheter Aortic Valve Replacement

Abstract

Objective: We report a case of cardiogenic shock, which was apparent soon after transcatheter aortic valve replacement (TAVR) and was refractory to medical therapy.

Case Presentations: An 86-year-old woman with symptomatic severe aortic stenosis was admitted to our hospital for TAVR. Transthoracic echocardiography showed a severely calcified aortic valve with the peak flow velocity of 4.6 m/s and the mean pressure gradient of 46 mmHg. Late peaking of left ventricular (LV) outflow tract acceleration with a V_max of 2.4 m/s at rest was observed. Coronary angiography revealed no significant coronary artery stenosis. A 23-mm SAPIEN 3 valve was successfully implanted with mild perivalvular leakage (PVL). The patient’s hemodynamic profile was stable as long as systolic blood pressure (BP) was maintained at >140 mmHg. However, when systolic BP was maintained at <110 mmHg, sudden hemodynamic collapse with a significant pressure gradient between the LV and aorta (Ao) was observed. Echocardiography revealed that the prosthetic valve functioned properly with mild PVL. Significant left ventricular outflow tract (LVOT) obstruction with systolic anterior movement and severe mitral regurgitation (with a maximum pressure gradient of 61 mmHg between the LV and Ao) was revealed. Given these findings, we considered that LVOT obstruction after removing the LV pressure overload with TAVR mainly contributed to hemodynamic collapse. We immediately started cibenzoline and a betablocker, and titrated this over 3 days. However, her hemodynamic status remained dependent on the afterload of catecholamines. Therefore, we decided to perform alcohol septal ablation (ASA). Isopropyl alcohol was infused into the two septal branches, and subsequent angiography revealed occlusion of the vessel. After ASA was performed, her hemodynamics improved, and the peak pressure gradient at the LVOT level demonstrated almost complete resolution (3 mmHg) on echocardiography. Catecholamines were successfully weaned off, and she was discharged without any complications.

Conclusion: Recognizing the physiological changes that can occur following TAVR is critical. Urgent ASA should be considered as an alternative treatment strategy for these patients.