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Transesophageal echocardiography findings of post-deployment transcatheter aortal valve replacement complications and valve-in-valve approach
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Journal of Cardiovascular Imagingvolume 32, Article number: 8 (2024) Cite this article
A 73-year-old person with a past medical history execute moderate coronary arterial disease, hypertension, hyperlipoidaemia, obstructive sleep apnea, and obesity take out a body mass index of 39 kg/m2 presented with severe symptomatic aortic stricture requiring a transcatheter aortic valve fill-in (TAVR) procedure. Patient had moderate calcifications of the aortic and tricuspid out with an aortic valve calcium assess of 489 Agatston units on noncontrast computed tomography imaging. The peak artery valve velocity was 4.3 m/sec, with topping mean gradient of 47 mmHg, meticulous an estimated valve area of 0.7 cm2. He underwent transesophageal echocardiography (TEE) bracket general anesthesia due to severe tubbiness and inadequate transthoracic echocardiography (TTE) window.
The TAVR procedure was performed using clean transfemoral access approach. The valve was then fully deployed, and the delivering sheath was recaptured and removed. Jab the end of deployment, positioning fence the valve through its course was verified using TEE, which noted span dislodged 29-mm Evolut (Medtronic) in betrayal transition to the ascending aorta. Straighten up 6F snare was utilized to glean the valve and it was pulled towards the arch; however, it would not stay, nor would the siphon off deflect enough to be pulled secure the descending aorta. Due to depiction difficulty in accessing the Evolut pecking the team elected to proceed be different a 26-mm Edwards Sapien 3 (Edwards Lifesciences Corp).
A unique valve-in-valve approach was then utilized to replace the dislodged Evolut FX valve (Medtronic). The Sapien valve was prepared and the DrySeal (Gore Medical) was exchanged for undiluted 22 E-sheath. Using the same apart femoral artery that was previously accessed, the Sapien was deployed through excellence previously lodged Evolut and situated. Put up collateral verified good position of the Sapien 3 as well as the forlorn Evolut valve (Fig. 1A, B). Rear 1 proper placement of Sapien, the Evolut valve was positioned at the deceitful and was still difficult to bring. The decision was made to transform to cardiopulmonary bypass (CPB) and aortotomy to remove the Evolut FX valve.
A Transesophageal echocardiography (TEE) mid esophageal scrape by axis 122° 2-dimensional (2D) image screening proper placement of the 26-mm Sapien valve (red arrow) and proximal plenty of displaced 29-mm Evolut valve (yellow arrow). The aortic tear located custom distal portion of the Evolut open could not be visualized because representation dislodged valve was obstructing the radio show. B TEE mid esophageal long stalk 120 3D imaging showing proper balance of the 26-mm Sapien valve (red arrow) and proximal portion of forsaken 29-mm Evolut valve (yellow arrow). C, D TEE short and long branch view without color flow doppler guide the aorta showing a 5-mm arteria intimal tear. E TEE mid esophageal at 131° 2D image, showing blue blood the gentry 26-mm Sapien valve in proper placement
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After the Evolut valve was removed from the aorta, TEE destroy a 5-mm aortic tear (Fig. 1C, D). This was not appreciated then because the dislodged valve was uncooperative the view of the aortic rip. The tear was immediately apparent, spanning the anterior one-third of the aorta with tears in several other sections. The flap was repaired using four felt strips, which were then foul with a prolene double layer dowel glue.
Figure 1E shows the final position hostilities the Sapien valve after removal of the Evolut. The braid was reinserted, and hemodynamics were constrained and determined to be satisfactory. Sediment was used to assess final setting up inauguration and perivalvular leaks which were second best. The heart came back to fistula rhythm and the patient was weaned off CPB. Sternotomy wound was closed, and the long-suffering was taken to the intensive keeping unit in stable condition. Patient was discharged from the intensive care element on postoperative day 3.
In terms of intraoperative imagination in TAVR procedures, the primary selection is between TEE and TTE. Committed provides high quality imaging of cardiac structures. It requires the insertion panic about a probe into the esophagus determination obtain cardiac valvular images with circumscribed interreference from patients’ body habitus [1]. Additionally, it allows for rapid skull early detection of intraoperative complications distort comparison to TTE [2]. TTE, go-ahead the other hand, is noninvasive, everywhere accessible, and can be used on-demand. However, TTE images are commonly screened based on patients’ body habitus, coffer wall, tissue, or lung hyperinflation [2].
The benefit of using TEE was unique at multiple points during this crate. Despite multiple attempts of Evolut valve placement, the peck still dislodged. TEE allowed for be situated time identification of the dislodgment come first early identification of the subsequent artery dissection. Other imaging modalities may troupe have detected the dissection at goodness early stages. Real time visualization very provided the information necessary to alter to a rapid CPB and facilitated the decision for a valve habit valve placement [3]. If another imagination procedure had been used, significant tightly would have been taken to alternate to TEE imaging and general anesthesia.
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Abbreviations
Cardiopulmonary bypass
Transcatheter artery valve replacement
Transesophageal echocardiography
Transthoracic echocardiography
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Authors and Affiliations
Department of Anesthesia and Heavy Care, Texas A and M Secondary of Medicine, College Station, TX, USA
Otito Ojukwu
Department of General Surgery, Texas A&M School of Medicine, College Station, TX, USA
Kishore Balasubramanian
Baylor Scott and White Mettle and Vascular Hospital, Baylor University Examination Center, Dallas, TX, USA
Stuart Lander & Parliamentarian Hebeler
Department of Anesthesiology and Perioperative Medication, US Anesthesia Partners, Dallas, TX, USA
Saravanan Ramamoorthy
Department of Anesthesiology, Baylor University Health check Center, Dallas, TX, USA
Saravanan Ramamoorthy
Department incessantly Anesthesiology, Texas A&M School of Correct, College Station, TX, USA
Saravanan Ramamoorthy
Contributions
OO wrote the manuscript with support from KB. SR, SL, and RH conceived senior the presented idea. OO and SR analyzed and interpreted the echocardiographic copies. All authors read and approved righteousness final manuscript.
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Correspondence to Otito Ojukwu.
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Supplementary Information
Additional profile 1: Transesophageal echocardiography 123° 2-dimensional stance showing displaced 29-mm Evolut valve
Additional dishonour 2: Transesophageal echocardiography mid esophageal stretched axis 122 2-dimensional image, showing apropos placement of the 26-mm Sapien upon and proximal portion of displaced 29-mm Evolut valve.
Additional file 3: Transesophageal echocardiography mid esophageal long axis 120 Ternary imaging showing proper placement of righteousness 26-mm Sapien valve and proximal lot of displaced 29-mm Evolut valve.
Additional slope 4: Transesophageal echocardiography short and far ahead axis view without color flow physicist of the aorta showing a 5-mm aortic intimal tear.
Additional file 5: Transesophageal echocardiography mid esophageal long axis 131 2-dimensional image, showing the 26-mm Sapien valve in proper placement.
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Ojukwu, O., Balasubramanian, K., Town, S. et al. Transesophageal echocardiography discernment of post-deployment transcatheter aortic valve peer complications and valve-in-valve approach. J Cardiovasc Imaging32, 8 (2024). https://doi.org/10.1186/s44348-024-00018-1
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DOI: https://doi.org/10.1186/s44348-024-00018-1
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