Author + information
- Received March 13, 2015
- Accepted March 26, 2015
- Published online August 17, 2015.
- Amornpol Anuwatworn, MD∗ ( )(, )
- Amol Raizada, MD,
- Shawn Kelly, MD,
- Tomasz Stys, MD,
- Orvar Jonsson, MD and
- Adam Stys, MD
- Sanford Cardiovascular Institute, Sanford University of South Dakota Medical Center, Sioux Falls, South Dakota
- ↵∗Reprint requests and correspondence:
Dr. Amornpol Anuwatworn, Sanford Cardiovascular Institute, Sanford University of South Dakota Medical Center, 1301 West 18th Street, Sioux Falls, South Dakota 57105.
A 78-year-old man presented with progressive dyspnea on exertion and syncope. His relevant history included coronary bypass surgery twice. Severe aortic stenosis with left ventricular ejection fraction of 65% was evident on echocardiography. Coronary angiogram showed patent left internal mammary artery and saphenous vein grafts with severe 3-vessel disease. Transesophageal echocardiogram revealed heavily calcified, poorly opening aortic valve leaflets, and a mobile echodense mass measuring 1 cm × 0.4 cm attached to the valve (Figure 1, Online Videos 1 and 2). Transfemoral transcatheter aortic valve replacement (TAVR) was performed with CoreValve system (Medtronic, Minneapolis, Minnesota), as the patient was deemed high risk for open heart surgery. After the procedure, most of the mobile aortic valve mass was no longer seen on the transesophageal echocardiogram. On awakening from sedation, right hemiplegia was noted (one-fifth strength). Head computed tomographic angiography showed narrowing involving the distal M1 segment of left middle cerebral artery (MCA) with diminished enhancement suggestive of early infarction. Emergent cerebral angiography showed a partially occlusive defect in the M1 segment of left MCA that was limiting the distal flow (Figure 2). Endovascular mechanical extraction of the mass responsible for these findings was performed with Penumbra ACE catheter (Penumbra, Inc., Alameda, California), achieving complete recanalization (Figures 3 and 4). Subsequently, the patient’s strength improved significantly (four-fifths strength). Brain magnetic resonance imaging revealed a large acute infarct of the left MCA territory (Figure 5). Histopathology of the extracted mass was consistent with heart valve tissue (Figure 6).
Stroke is a well-known complication of TAVR. The incidence rate of major strokes at 30 days in the PARTNER (Placement of Aortic Transcatheter Valves) A trial was 3.8% (1). Svensson et al. (1) found that 51% of strokes occurred during the procedure, and 38% of strokes occurred within 2 days; however, the mortality rate in patients with stroke was 43%. Of patients undergoing TAVR, 0.56% developed valve embolization (2). One case report of a TAVR patient demonstrated the successful endovascular retrieval of an embolized calcium fragment that may have derived from the aortic wall or the valve (3). In our case, the valve tissue recovery from the MCA resulted in significant neurological improvement. To our knowledge, this case demonstrates the first successful endovascular recanalization of acute ischemic stroke caused specifically by valve tissue embolization. Endovascular intervention should be considered as emergency rescue therapy for acute ischemic stroke resulting from valve tissue emboli.
The authors thank Dr. Jitendra Sharma for providing advanced interventional neurology care and post-procedure photographs of retrieved valvular tissue. Special thanks to Dr. David W. Ohrt and Dr. Usama Yusef for providing the histopathology slide.
For accompanying videos, please see the online version of this paper.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received March 13, 2015.
- Accepted March 26, 2015.
- American College of Cardiology Foundation
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