Ascending aorta perforation with cardiac tamponade 19 days after transcatheter aortic valve implantation

A 83-year-old Caucasian male, known with chronic pulmonary disease, mild renal insufficiency, hypertension and epilepsy, was admitted to our tertiary referral centre for aortic valve replacement because of symptomatic severe aortic stenosis. Echocardiography showed aortic stenosis with a peak gradient of 100 mmHg (aortic valve area 0.5 cm2) and a hypertrophic left ventricle with moderate systolic function (LVEF 50%). The diameter of the ascending aorta was 33 mm on echocardiography and the aortic valve was functionally bicuspid, with tricuspid architecture and fusion of two leaflets. Coronary angiography showed coronary atherosclerosis without significant stenosis. The logistic EuroSCORE was 11.02%. The multidisciplinary heart team considered the patient at high risk for conventional surgery because of comorbidities, frailty and age. Transcatheter aortic valve implantation (TAVI) was judged to be the optimal therapeutic option. The TAVI procedure was performed under general anaesthesia with vascular access through the left subclavian artery, which is the access site of choice in our centre. The native valve with an annular dimension of 25 mm, as assessed by transoesophageal echocardiography, was predilatated with a 22 mm Nucleus balloon (NuMED Inc.) under rapid pacing. A 29 mm Medtronic CoreValve® was inserted and deployed. After implantation a mild gradient and moderate paravalvular leakage were observed, due to extensive local annular calcification. After two postdilatations of the prosthesis at the aortic valve annulus, both the