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TAVR Explantation Due to Late Thrombosis Leading to Cardiogenic Shock

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posted on 19.07.2022, 18:39 authored by Qasim Al Abri, Lamees I. El Nihum, Mahesh K. Ramchandani, Michael J Reardon

This is the case of a transcatheter aortic valve replacement (TAVR) explantation due to late thrombosis leading to cardiogenic shock. 

The patient was a sixty-seven-year-old woman with a complex medical history. She underwent a TAVR procedure forty months prior. Compared to her initial normal valve hemodynamics, the patient presented with high gradients and velocities across the valve in the observed procedure. A transesophageal echocardiogram showed thrombosed valve leaflets and high gradients across the valve. A corresponding TAVR-protocol computed tomography (CT) scan confirmed the finding. 

The patient was started on oral anticoagulants, but two weeks later, she presented with cardiogenic shock. The condition required use of an intra-aortic balloon pump (IABP) and two inotropic supports. The patient also had bowel ischemia and shock liver that was judged to be caused by low flow. Correspondingly, the patient was admitted to the ICU. 

The operation team decided that the patient was not a candidate for valve-in-valve. The consensus derived from the presence of hostile root anatomy and risk of embolization. Thus, surgical explantation and aortic valve replacement was the only available option, despite the patient’s high risk. 

The Operation

Following cardiopulmonary bypass, the heart was arrested and the aorta was opened above the frame of the previous TAVR valve. Proper exposure was achieved. The previous TAVR valve was inspected carefully to confirm the pathology. Surgical explantation was started by careful and meticulous initiation of the right plane between the valve and the aorta to avoid any aortic injury. This was performed by retracting the valve through the midline using two forceps. The plane was initiated totally around the valve. 

Next, a purse-string suture was placed around the top frame of the valve using 3-0 Prolene. The suture was snared down to collapse the valve to the midline. This technique helps to collapse the valve to the midline to avoid any aortic injury. Furthermore, the technique was used as a good handle to manipulate the valve during the continued dissection of the plane all the way down to the native aortic valve leaflets. Once the native leaflets were reached, dissection was started between the leaflets and the transcatheter valve. This was done in all three leaflets to create a safe plane for dissection all the way down in the left ventricular outflow tract (LVOT). Both Metzenbaum scissors and a no. 15 blade were used in the dissection. 

Once the plane between the native leaflets and the transcatheter valve was created, the dissection proceeded to free the valve from the LVOT. This was performed very carefully to avoid any injury to the surrounding tissues. Following the dissection, the valve was retracted, all of the attachments were dissected carefully, and the valve was fully explanted. Inspection of the valve showed three thrombosed leaflets and extensive endothelialization around the valve from both the inflow and the outflow. 

Following inspection, the native aortic valve leaflets were excised by means of regular surgical aortic valve replacement. Next, careful debridement and decalcification procedures were performed. Irrigation was then done to flush all the debris out of the left ventricle. After valve sizing was performed, regular mattress pledgeted annular sutures were placed around the annulus in a regular fashion. The surgical aortic valve was placed, and all the sutures were tied down. Afterward, the valve was inspected; it appeared well-seated. 

Closing Remarks

The aortotomy was closed, and the patient was weaned from the cardiopulmonary bypass. The operation was completed in a standard fashion. Furthermore, the patient required no inotropic support and was extubated in the same operative day. Finally, the IABP was removed the next day. The rest of the hospital stay was unremarkable; the patient was discharged from the hospital after twelve days.

References

1. Bapat VN, Zaid S, Fukuhara S, Saha S, Vitanova K, Kiefer P, Squiers JJ, Voisine P, Pirelli L, von Ballmoos MW, Chu MWA, Rodés-Cabau J, DiMaio JM, Borger MA, Lange R, Hagl C, Denti P, Modine T, Kaneko T, Tang GHL; EXPLANT-TAVR Investigators. Surgical Explantation After TAVR Failure: Mid-Term Outcomes From the EXPLANT-TAVR International Registry. JACC Cardiovasc Interv. 2021 Sep 27;14(18):1978-1991. Doi: 10.1016/j.jcin.2021.07.015. PMID: 34556271.

2. Fukuhara S, Brescia AA, Shiomi S, Rosati CM, Yang B, Kim KM, Deeb GM. Surgical explantation of transcatheter aortic bioprostheses: Results and clinical implications. J Thorac Cardiovasc Surg. 2021 Aug;162(2):539-547.e1. doi: 10.1016/j.jtcvs.2019.11.139. Epub 2020 Jan 12. PMID: 32037245; PMCID: PMC7388726. 

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