Experience in Treating a Case of Cardiac Rupture During Transcatheter Aortic Valve Implantation Procedure
Transcatheter aortic valve implantation (TAVI) has emerged as a minimally invasive alternative to surgical aortic valve replacement, particularly for patients with severe aortic stenosis who are at high surgical risk. However, despite its advantages, TAVI is not without complications. One of the most life-threatening complications is cardiac rupture, which requires prompt diagnosis and immediate intervention. This article presents a detailed account of a case involving cardiac rupture during TAVI, highlighting the critical steps taken to manage this complication and the lessons learned from the experience.
The patient in this case was a 70-year-old male with severe aortic stenosis. Preoperative echocardiography revealed a peak aortic valve velocity of 4.33 m/s, a peak pressure gradient of 75 mmHg, and a mean pressure gradient of 38 mmHg. The left ventricular end-systolic and end-diastolic dimensions were 31.7 mm and 50.0 mm, respectively. The aortic annular internal diameter measured 30.7 mm, and the aortic sinus diameter was 37.3 mm. The aortic valve area was calculated to be 0.87 cm². Computed tomography (CT) imaging indicated a bicuspid aortic valve with a diameter of 27.3 mm based on an 85.6 mm perimeter of the aortic annulus, or 27.4 mm based on a valve orifice area of 569 mm². A 26 mm Venus-A valve (Venus Medtech, Hangzhou, China) was selected for implantation.
During the procedure, a 20Fr balloon was used to dilate the aortic valve. Within five minutes of balloon dilation, the patient’s systolic blood pressure dropped to 70 mmHg. Transesophageal echocardiography (TEE) revealed a rapidly increasing pericardial effusion, prompting immediate intervention. A single-chamber central venous catheter was inserted into the pericardial cavity through the left fourth intercostal space. Approximately 500 mL of bright red hemopericardium was quickly aspirated and infused back into the patient’s circulation via the left femoral artery. Although the patient’s blood pressure stabilized, the pericardial effusion persisted, as confirmed by TEE.
Given the persistent effusion and the bright red color of the aspirated blood, a left ventricular rupture was suspected. Color Flow Doppler imaging confirmed this suspicion, showing a jet of blood ejecting from the left ventricle into the pericardial cavity. An urgent thoracotomy was performed through a median sternal incision. Upon inspection of the left ventricular surface, a 1 cm gap was identified, located 8 mm away from the left anterior descending branch and parallel to the ventricular septum. Blood was observed ejecting from this gap with each heartbeat. The defect was repaired using two interrupted horizontal mattress sutures with 2-0 Prolene on two felts. Postoperatively, the patient experienced no myocardial infarction, stroke, incision infection, or conduction block and was discharged nine days later.
This case underscores the importance of a multidisciplinary approach to TAVI, involving both interventional cardiologists and cardiac surgeons. The procedure must be performed in a hybrid operating room equipped with cardiopulmonary bypass instruments on standby. The integration of internal and surgical technologies is essential for ensuring patient safety, particularly in managing severe complications such as cardiac rupture. The disinfection and draping protocols for TAVI should adhere to surgical standards, and the patient’s chest should be fully exposed to facilitate urgent thoracotomy if necessary. At least one cardiac surgeon should be present during the procedure to provide immediate surgical intervention if required.
Cardiac rupture during TAVI is a rare but devastating complication. Predisposing factors include a calcified aortic annulus, fragile myocardium, and previous ischemic heart disease. Common causes of cardiac rupture include damage to the left ventricle by a stiff guidewire and rupture of the aortic annulus during balloon dilation. The most frequently injured site is the anterior wall of the left ventricle, approximately 2 cm lateral to the left anterior descending artery. TEE and continuous blood pressure monitoring are critical for early diagnosis, as massive pericardial effusion and a drop in blood pressure are strong indicators of cardiac rupture.
In this case, the cardiac rupture was attributed to the stiff guidewire. During balloon dilation, the guidewire slipped transiently into the left ventricle, causing it to cut through the myocardium along the interventricular septum. Stiff guidewires provide essential support for valve delivery but pose a significant risk of myocardial trauma. Operators must remain vigilant, especially when dealing with patients who have a small left ventricular cavity, hypercontractile thin myocardium, or a narrow aorto-mitral angle. Elderly female patients with these risk factors require particular attention to prevent cardiac rupture.
To manage cardiac rupture during TAVI, pericardiocentesis should be performed immediately to relieve cardiac tamponade. A three-way plug valve and transfusion tube can be used to connect the pericardial drainage tube to the femoral artery sheath, allowing for rapid reinfusion of aspirated blood. Surgical intervention should be initiated as soon as possible to repair the defect and prevent further complications. Prolonged poor perfusion can lead to multiple organ failure, emphasizing the need for prompt and effective management. Care must also be taken to avoid secondary injury to the coronary arteries during surgical repair.
In conclusion, this case highlights the critical importance of a multidisciplinary approach to TAVI, particularly in managing severe complications such as cardiac rupture. Early diagnosis, immediate intervention, and the presence of a cardiac surgeon during the procedure are essential for ensuring patient safety. The integration of interventional and surgical techniques, along with adherence to strict procedural protocols, can significantly reduce the risk of life-threatening complications and improve patient outcomes.
doi.org/10.1097/CM9.0000000000001098
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