Early Migration of a Self-Expanding Transcatheter Aortic Valve Prosthesis Causing Coronary Occlusion: A Practical Technique for Surgical Explantation
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Transcatheter aortic valve replacement (TAVR) has become the standard of care for high-risk patients and is growing in popularity for lower risk patients. The authors report a case of early migration of a self-expanding transcatheter aortic valve prosthesis causing coronary obstruction and myocardial infarction.
A 76-year-old woman with renal failure underwent an uncomplicated TAVR. Thirty-two days later she presented with acute angina, ruled-in for myocardial infarction, and was found to have iatrogenic coronary obstruction from the aortic valve prosthesis due to cephalad migration.
The patient was taken to the operating room where a transverse aortotomy was made at the normal anatomic site (not cephalad to the prosthesis), exposing the metal stent component of the failed device. Multiple attempts at extraction were attempted, however the device was tightly adherent to the left ventricular outflow tract. A 3-0 Prolene suture was weaved through the stent to create a purse string and the suture was snared counteracting the radial force and thus reducing the circumference of the device. The prosthesis was subsequently removed without incident. A surgical aortic valve replacement was then carried out using a 21 mm bovine pericardial bioprosthesis. Cardiopulmonary bypass time was 81 minutes and aortic cross-clamp time was 63 minutes. The patient tolerated the procedure well.
Early migration is a rare complication after TAVR. Self-expanding prosthetic devices may require the use of techniques to counteract the radial forces exhibited on the wall of the left ventricular outflow tract. This report describes a near-lethal early complication and a technique that worked well to facilitate device removal.
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