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Patient initials or identifier number
Relevant clinical history and physical exam
A 76 years-old female with history of atrial fibrillation, hypertension, breast cancer, severe lung disease, and stroke. She presented with decrease in exercise tolerance with NYHA III. Physical examination showed 4/6 ejection systolic murmur over aortic area with radiation to the neck. Body weight was 94 kg and height was 164 cm.
Relevant test results prior to catheterization
Echo showed severe trilea flet aortic stenosis with aortic valve area of 0.7 cm2 with mean gradient of 25 mmHg and peak gradient 43 mmHg. Stress echocardiogram showed evidence of paradoxical low flow low gradient severe aortic stenosis. Left ventricular ejection fraction of 55%. Electrocardiogram showed atrial fibrillation with QRS 94 ms. A creatinine was normal. CT prior TAVI showed annular diameter of 19.5 x 28.6 mm with average diameter of 24 mm. Perimeter was 76 mm. Area was 428.6 mm2. Left ventricular outflow tract was 76.2 mm. sinus of valsalva was 27 x 27. minimal right femoral diameter 6 mm.
Relevant catheterization findings
A coronary angiogram showed no significant stenosis.
The initial plan was to perform TAVI through right femoral approach. 7 French sheath was inserted on the left side for pigtail catheter insertion and 6 french catheters for temporary pacemaker lead. Crossover technique was done with 6Fr IM catheter with 0.35 hydrophilic Terumo wire. However, after successful puncture of a right femoral artery and 6 French sheath and exchange with 0.38 inch Jwire, there was difficulty in passing Prostar down due to thick subcutaneous fat. Even Proglide failed to pass down the subcutaneous fat due to inadequate support. Therefore, the left 7Fr sheath was exchanged to 8Fr arrow sheath and repeated cross over technique to the right side was done and a platinum wire was used for support from left femoral access to allow snaring of the closure device from left side without success. There was a sudden drop in blood pressure with systolic blood pressure of 60 mmHg and heart rate of 125 beats per minute. Bedside echocardiogram showed no pericardial effusion with preserved left ventricular ejection function. Angiogram was done to the right and left femoral arteries showed no significant evidence of contrast leakage. (holm initial perforation.mov) Therefore, another arterial puncture was done on the left femoral arterial access with successful insertional of Prostar and 22Fr Boston sheath. There was again a transient episode of a drop in blood pressure to a systolic pressure of 70 mmHg and responded to a fluid challenge. Heparin was injected when blood pressure stabilized. Lotus 25 was deployed through left femoral approach. There was progressive abdominal swelling and blood pressure remained low despite fluid challenge despite valve deployment. Repeated echocardiogram showed normal functioning valve prosthesis and no evidence of pericardial effusion. Aortogram through a 6 Fr Pigtail catheter showed contrast extravasation from an upper end of the right iliac artery near the bifurcation. Three overlapping 8 mm via Bahn was deployed over right iliac artery with aortic balloon tamponade finally stabilized the patient's blood pressure and final aortogram showed no evidence of contrast extravasation.
In patients with high body mass index, there is often difficulty in insertion of closure devices. One may consider the use of stronger support wires such as Amplatz superstiff to facilitate device insertion. Pathophysiology of paradoxical low flow low gradient aortic stenosis is complex. It is essential for early recognition of vascular complications especially in small tortuous vessels to avoid catastrophe.