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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 23  |  Issue : 4  |  Page : 226-229  

Early hemodynamic recovery after a successful transcatheter aortic valve implantation in cardiogenic shock secondary to severe bicuspid aortic stenosis


1 Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne, UK
2 Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne; School of Life and Medical Science, University of Hertfordshire, UK
3 Department of Cardiology, Freeman Hospital; Translation and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK

Date of Submission06-Apr-2022
Date of Acceptance09-Oct-2022
Date of Web Publication17-Nov-2022

Correspondence Address:
Dr. Mohammad Alkhalil
Department of Cardiology, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, NE7 7DN
UK
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/heartviews.heartviews_35_22

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   Abstract 


Pulmonary edema secondary to severe aortic stenosis is an emergency condition that carries a high risk of mortality and is resistant to treatment using standard heart failure therapies. We present here a patient with severe aortic stenosis, complicated by poor left ventricular function and cardiogenic shock, who has immediate hemodynamic recovery after successful balloon aortic valvuloplasty and transcatheter aortic valve implantation (TAVI) procedures.This case presentation highlights the efficacy of using the TAVI procedure in the management of severe aortic stenosis complicated by acute heart failure and cardiogenic shock with immediate improvement of hemodynamic parameters more effectively sooner after the procedure.

Keywords: Aortic stenosis, balloon aortic valvuloplasty, cardiogenic shock, transcatheter aortic valve implantation


How to cite this article:
Ibrahem A, Farag M, Alkhalil M. Early hemodynamic recovery after a successful transcatheter aortic valve implantation in cardiogenic shock secondary to severe bicuspid aortic stenosis. Heart Views 2022;23:226-9

How to cite this URL:
Ibrahem A, Farag M, Alkhalil M. Early hemodynamic recovery after a successful transcatheter aortic valve implantation in cardiogenic shock secondary to severe bicuspid aortic stenosis. Heart Views [serial online] 2022 [cited 2022 Dec 8];23:226-9. Available from: https://www.heartviews.org/text.asp?2022/23/4/226/361397




   Introduction Top


Pulmonary edema secondary to severe aortic stenosis is an emergency condition that carries a high risk of mortality and is resistant to treatment using standard heart failure therapies.

We present here a patient with severe aortic stenosis, complicated by poor left ventricular function and cardiogenic shock, who has immediate hemodynamic recovery after successful balloon aortic valvuloplasty and transcatheter aortic valve implantation (TAVI) procedures.


   Case Presentation Top


A 79-year-old male, with a known case of severe aortic stenosis secondary to bicuspid aortic valve disease was scheduled for an elective TAVI procedure after a multidisciplinary team discussion. He was admitted with progressive shortness of breath and signs suggestive of pulmonary edema and decompensated severe left ventricular dysfunction. An echocardiogram showed a severe bicuspid aortic valve stenosis with a peak/mean gradient of 90/40 mmHg and valve area of 0.3 cm2, dimensionless index of 0.09, with severe left ventricular failure (ejection fraction 10%–15%). Collectively, this showed a critical transaortic gradient in the context of severe left ventricle (LV) dysfunction [Figure 1]. A previous gated computed tomography coronary angiogram demonstrated a bicuspid aortic valve with severely calcified leaflets [Figure 2].
Figure 1: Gated CT coronary angiogram demonstrate bicuspid aortic valve, with heavy calcified aortic root. CT TAVI illustrated bicuspid aortic valve with heavy leaflets calcification. CT: Computed tomography, TAVI: Transcatheter aortic valve implantation

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Figure 2: Transthoracic echocardiography measuring transvalvular gradient and velocity prior TAVI procedure shows severe aortic stenosis with a peak velocity of 4.73 m/s and an aortic valve area of 0.3 cm2, peak gradient 89.58 mmHg, mean gradient 39.72 mmHg. TAVI: Transcatheter aortic valve implantation

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Despite maximum medical therapy, the patient started developing cardiogenic shock with persistently low blood pressure (BP) (systolic BP 60–70 mmHg) requiring vasopressor and a heart rate of 120 bpm. A decision was made to perform an emergency TAVI. This was performed through the right femoral artery with a 20 mm cristal balloon [Figure 3] and a subsequent 29 mm Sapien S3 prosthetic valve (Edward life science) under rapid pacing [Figure 4]. Immediately, following TAVI, a significant improvement in hemodynamics was noted with a rise in blood pressure and a reduction in heart rate without the need for inotropic support.
Figure 3: Aortography with the balloon fully inflated prior to TAVI with rapid pacing facilities. TAVI: Transcatheter aortic valve implantation

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Figure 4: Aortography shows deployment and dilatation of 28 mm Edward SAPIEN prosthetic valve in place

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Post-TAVI echocardiogram showed a well-functioning aortic valve with no significant para-valvular regurgitation.

The patient made an uneventful recovery and was discharged home on day 2 postprocedure. Echocardiogram 90 days postprocedure showed a well-functioning aortic valve with a mean gradient of 8 mmHg and significant improvement in left ventricular systolic function (ejection fraction from 15% to 50%) [Figure 5] and [Figure 6].
Figure 5: Repeated transthoracic echocardiography measuring transvalvular gradient and velocity 90 days post-TAVI procedure confirm valve in correct position, with peak gradient 16.99 mmHg/mean gradient 8.42 mmHg and significant improvement in left ventricular systolic function (ejection fraction 50%). TAVI: Transcatheter aortic valve implantation

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Figure 6: Repeated transthoracic echocardiography measuring transvalvular gradient and velocity 90 days post-TAVI procedure confirm valve in the correct position, with peak gradient 16.99 mmHg/mean gradient 8.42 mmHg and significant improvement in left ventricular systolic function (ejection fraction 50%). TAVI: Transcatheter aortic valve implantation

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   Discussion Top


TAVI procedure is a standard treatment for patients with severe aortic stenosis. This case highlights that TAVI is also a life-saving procedure in the context of cardiogenic shock secondary to severe aortic stenosis. It is associated with significant improvement in LV function post-TAVI.[1]

In a retrospective multicenter registry of TAVI in cardiogenic shock, Fraccaro et al. reported the successful rate of TAVI in cardiogenic shock are significantly high 94%, with a mortality rate up to 12% after 30-days, with lower event rate in the long-term follow-up. In contrast, mortality risk in surgical AVR is up to 25%, and even worse in patients undergoing BAV alone and estimated up to 70%. Moreover, despite high risk of mortality, BAV still remains a valid option in critical aortic stenosis as palliative or bridge procedure.[2]

Byrne et al. presented a comprehensive report of emergency TAVI in cardiogenic shock and cardiorenal syndrome secondary to severe bicuspid aortic stenosis in the same cohort of patient. Our case adds to the role of TAVI in complex anatomy, i.e., bicuspid aortic valve. Further data to support the use of TAVI in bicuspid valve are needed.[3]


   Conclusion Top


This case presentation highlights the efficacy of using TAVI procedure in the management of severe aortic stenosis complicated by acute heart failure and cardiogenic shock with immediate improvement of hemodynamic parameters more effectively sooner after procedure

Disclosure

We would like to state that there is no relationship with industry exists in relation to this manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Unbehaun A, Pasic M, Buz S, Dreysse S, Kukucka M, Hetzer R, et al. Transapical aortic valve implantation in patients with poor left ventricular function and cardiogenic shock. J Thorac Cardiovasc Surg 2014;148:2877-82.e1.  Back to cited text no. 1
    
2.
Fraccaro C, Campante Teles R, Tchétché D, Saia F, Bedogni F, Montorfano M, et al. Transcatheter aortic valve implantation (TAVI) in cardiogenic shock: TAVI-shock registry results. Catheter Cardiovasc Interv 2020;96:1128-35.  Back to cited text no. 2
    
3.
Byrne L, Wheen P, O'Connor S. Emergency TAVI in cardiogenic shock and cardiorenal syndrome secondary to severe bicuspid aortic stenosis. BMJ Case Rep 2021;14:e239003.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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