Author + information
- Creighton W. Don, MD, PhD∗ (, )
- James M. McCabe, MD and
- Corinne L. Fligner, MD
- ↵∗Reprint requests and correspondence:
Dr. Creighton W. Don, University of Washington Medical Center, Medicine–Division of Cardiology, 1959 NE Pacific Street, 356422, Seattle, Washington 98195.
An 87-year-old patient with severe aortic stenosis underwent transapical transcatheter aortic valve replacement with a 26-mm Edwards Sapien valve (Edwards Lifesciences, Irvine, California). Pre-operative imaging was notable for severe asymmetric calcification along the posterolateral aspect of the left ventricular outflow tract (LVOT) involving the intravalvular fibrous curtain (Figure 1). The aortic annulus area measured 430 mm2 by computed tomographic imaging, allowing for 23% oversizing. Valve deployment was appropriate but was remarkable for moderate paravalvular regurgitation at the site of the LVOT calcification. The valve was redilated with an additional 1 ml of fluid added to the delivery balloon, modestly reducing the regurgitation. The patient recovered well and experienced mild heart failure symptoms. On hospital day 4, the patient experienced a cardiac arrest and underwent 48 min of cardiopulmonary resuscitation without return of spontaneous circulation. Autopsy demonstrated that the Sapien valve was crushed, with deformation of the valve at the site of the LVOT calcium (Figure 2, Online Video 1). Such severe valve distortion would have significantly impaired leaflet coaptation and function, and it is likely that successful resuscitation was impossible once the valve was crushed (1). The LVOT calcium caused significant paravalvular leak and likely contributed to valve deformation during chest compressions (Figure 3, Online Video 1). Care must be taken when providing cardiopulmonary resuscitation to patients with balloon-expandable transcatheter aortic valve prostheses, and follow-up imaging to evaluate valve deformation is crucial.
For a supplemental video and its legend, please see the online version of this article.
Dr. McCabe has served as a proctor for Edwards LifeScience. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation