Author + information
- Ryosuke Higuchi1,
- Tetsuya Tobaru1,
- Kenichi Hagiya1,
- Mike Saji1,
- Keitaro Mahara1,
- Itaru Takamisawa1,
- Jun Shimizu1,
- Nobuo Iguchi1,
- Shuichiro Takanashi1 and
- Morimasa Takayama1
Patient initials or identifier number
Relevant clinical history and physical exam
Our case was an 81-year-old male with severe aortic stenosis. Because he had several comorbidities including collagen disease and interstitial pneumonitis needing corticosteroids and home oxygen therapy, we selected transfemoral transcatheter aortic valve implantation (TAVI) using self-expanding valve.
Relevant test results prior to catheterization
Laboratory findings: Creatinine 2.3 mg/dl, eGFR 23 ml/min, NT-pro BNP 3625 pg/ml.
Echocardiography: Severe aortic stenosis due to bicuspid aortic valve (aortic valve area 0.70 cm2, peak pressure gradient 114 mmHg, mean pressure gradients 60 mmHg). Ejection fraction 62%.
MR angiography: Severe stenosis of left internal carotid artery. Suspected occlusion of left vertebral artery.
Pulmonary functional test: FVC 68%, FEV1.0 1.56L, FEV1 75%.
Relevant catheterization findings
Severe stenosis of proximal right coronary artery.
At first, we intervened proximal right coronary artery. Following successful balloon aortic valvuloplasty, we tried to deploy self-expanding valve. When prosthetic valve started to expand, blood pressure suddenly declined to 40-50 mmHg. Echocardiography showed acute severe mitral regurgitation (MR), and bleeding blew out from his airway. The prosthetic valve was deployed at optimal position, and stiff-guide wire was extracted from left ventricle. Severe MR had smoothly regressed, and hemodynamics became stable in parallel.
Post-procedural chest X-ray depicted bilateral pleural hematoma and left lung hemorrhage. Interference of the left ventricular guide wire with mitral sub-valvular structure and restriction of forward left ventricular flow by prosthetic valve led to severe MR and pulmonary hemorrhage. We sought to stop bleeding with vitamin K, fresh frozen plasma and hemostatic drug. Respiratory failure was managed by non-invasive positive pressure ventilation. During TAVI, careful attention should be paid to position of guide wire, change of hemodynamics and degree of MR.