Embolization of a Fully-Deployed Transcatheter Aortic Valve Implant Caused by Chest Compression During Cardiopulmonary Resuscitation

We report a case of 74-year-old woman who developed an embolized transcatheter aortic valve implant after cardiopulmonary resuscitation (CPR), which is unexpected sequel CPR.1Otto C.M. Nishimura R.A. Bonow R.O. et al.2020 ACC/AHA guideline for the management patients with valvular heart disease: executive summary: American College Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.Circulation. 2021; 143: e35-e71https://doi.org/10.1161/CIR.0000000000000932Crossref PubMed Scopus (601) Google Scholar A second was implanted, capturing distal frame (valve-in-valve strategy). Moreover, this highlights feasibility, safety, and efficacy using approach to avoid need surgical bailout. presented exertional shortness breath caused by low gradient, normal ejection fraction, severe stenosis. She functionally limited, favored replacement (TAVR) consensus during team discussion. Given area perimeter annulus, 26-mm Evolut Pro Plus (Medtronic) deemed appropriate. 14F Sentrant sheath placed in right femoral artery, 6F radial artery enabled placement pigtail catheter noncoronary cusp root aortograms. An Amplatz-1 used cross native (AV), regular SAFARI wire (Boston Scientific). The delivered AV through delivery system inline commissural alignment, pacing at 140 bpm later stages deployment. 3-mm depth deployment planned. After successful deployment, removed, reinsertion Medtronic over situ (Figure 1A Supplemental Videos 1 2). There drop gradients between pre-TAVR post-TAVR from 34 0 mm Hg negligible regurgitation (AR) 1B, C). procedure successful, plan had been end aortogram document expansion lack paravalvular leak. left ventricular (LV) removed 0.035-inch exchange J wire; unfortunately, it pulled out sheath. To reinsert sheath, dilator reintroduced, unit pushed without initial fluoroscopic guidance. resistance noted, angiographic image revealed perforation common (CFA), sheath-dilator having transected residing outside arterial structures 1D). did not provide same stiffness as keep being directed toward wall, resulting perforation. patient became hypotensive went into hemorrhagic shock cardiac arrest. CPR started immediate intubation aggressive fluid inotrope resuscitation. external iliac stented two 6 × 37-mm stent grafts seal CFA Final cine imaging showed good sealing no residual leak 1E). regained return spontaneous circulation (ROSC) but continued be even vasopressor support. recheck embolization valve, occlusion coronary arteries concomitant AR 1F Video 3). Then, EN-Snare inserted (LFA) snare ascending aorta re-establish blood flow. crimped prepared LFA. Another LFA Amplatzer Superstiff wire, LV re-entered catheter. place while making sure that both passed within aorta. Attempts were thwarted its interaction first deployed pushing latter down back sinuses. Therefore, held EN-Snare, whereas positioned annulus 1G, H 4 5). Valve release performed bpm. This postdilated 21-mm Crystal balloon obtain optimal decrease Repeat hemodynamic assessment trivial excellent flow 1I, 6). remained unresponsive comatose. Her stay also complicated sepsis ventilator-associated pneumonia. died 7 weeks procedure. In our case, underwent CPR, including chest compressions, owing iatrogenic shock. high quality forceful compression exposed extreme mechanical force, and, subsequently, severely ischemic myocardium because occluded ostia combined torrential AR. Those serial complications together made sustained ROSC extremely challenging. Our self-expanding TAVR prosthesis managed strategy proximal capture one (double-valve technique). By fixing one, risk additional migration mitigated. causes device are classified procedural preprocedural causes. include anatomic causes, such sizing errors, bicuspid AV, anatomy (horizontal aorta), absence calcifications. Procedural subdivided those related positioning errors issues.2Rouleau S.G. Brady W.J. Koyfman A. Long B. Transcatheter complications: narrative review emergency clinicians.Am Emerg Med. 2022; 56: 77-86https://doi.org/10.1016/j.ajem.2022.03.042Abstract Full Text PDF (2) should alert cardiologists fact may cause postprocedural embolization. knowledge, reported CPR. Nevertheless, there have reports deformed valves or secondary suboptimal confirmed result.3Ibebuogu U.N. Giri S. Bolorunduro O. al.Review following trans-catheter implantation.Am Cardiol. 2015; 115: 1767-1772https://doi.org/10.1016/j.amjcard.2015.03.024Abstract (35) illustrates possible complication. Care must taken when providing bioprostheses, instant crucial unexplained refractory arrest achievement evaluate position expansion.