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Relevant clinical history and physical exam
A 62-year-old male with a history of Bentall procedure and mechanical aortic prosthetic valve replacement, hypertension, hyperlipidemia, chronic kidney disease, and antiphospholipid syndrome presented with sudden onset of dyspnea at rest. Examination showed marked hypotension and tachycardia, with a 3/6 crescendo-decrescendo murmur at the right upper sternal border. The patient noted to have crackles in the lungs throughout bilaterally and marked jugular venous distension.
Relevant test results prior to catheterization
He underwent laboratory investigations, including a creatinine of 2.6 mg/dl (normal, 0.7-1.3) and NT-pro-BNP of 52,000 pg/mL (normal, <300). Echocardiogram showed biatrial and right ventricular enlargement with moderate aortic and mitral regurgitation with preserved ejection fraction. Mean gradient across the aortic valve was 46 mmHg with a peak gradient of 80 mmHg. CT chest revealed a large thrombus obstructing the prosthetic valve and valve fluoroscopy demonstrated a fixed posterior disc.
Relevant catheterization findings
The patient underwent PEA arrest and subsequently placed on veno-arterial ECMO support. Hemodynamic catheterization was performed demonstrating a pulmonary artery mean pressure of 65 mm Hg, left atrial mean pressure of 58 mm Hg and indicating severe pulmonary hypertension with right-sided pressure overload secondary to the left sided aortic valve thrombus.
Atrial septostomy performed using a 20 mm Tyshak Balloon over an Amplatz wire in the left superior pulmonary vein in an effort to decompress the left ventricle. This successfully performed, in the setting of active ECMO therapy, forming a large continuous left-to-right shunt. Pulmonary artery mean pressure immediately decreased to 38 mmHg with left atrial mean pressure of 27 mmHg. Marked reduction in left atrial v-waves was seen. Shortly following the intervention, the ECMO oxygen requirements noted to diminish and the patient's urine function improved.
This improvement in the patient’s condition facilitated the redo surgery which involved removal of thrombosed mechanical prosthetic aortic valve followed by aortic root replacement utilizing a 23-mm On-X composite valved conduit, closure of iatrogenic atrial septal defect and decannulation of VA ECMO. Echocardiogram performed nine days following surgery showed mild LV enlargement, an estimated RVSP of 28 mmHg, aortic valve prosthesis mean gradient of 8 mmHg and an EF of 60%. The patient was discharged after 33 days of hospitalization. Three months later, he had made a full recovery and had no residual cardiac symptoms.