Since the first use of transcatheter aortic valve replacement (TAVR) in 2002, the number of patients who underwent this relatively new procedure now exceeds 50,000.1 The prospective, randomized PARTNER study, which included >1000 patients, showed a significant reduction in mortality among patients who underwent TAVR versus optimal medical management and the noninferiority of TAVR to standard open valve replacement.2 Today, TAVR is considered the standard treatment for patients who are not surgical candidates.
Although TAVR has received much attention and is offered to patients as a less invasive alternative to traditional open aortic valve replacement, TAVR is not without serious risk. Arrhythmias, heart block, ischemia, new aortic regurgitation, tamponade, and stroke have all been encountered perioperatively and in the postoperative period in TAVR patients.3 These risks are associated with preexisting comorbidities, the type of valve implanted, and the choice of insertion site.4 It is therefore critical that patient selection and perioperative care decisions be made by a team of cardiologists, interventionalists, cardiothoracic surgeons, cardiac anesthesiologists, and intensivists equipped with the knowledge and resources to identify and manage all potential complications.
We describe a case of cardiac tamponade after a TAVR performed through a direct aortic approach. We were unable to contact the patient or the family by telephone for consent, and our institution’s IRB did not require review for this case.
A 70-year-old man with a history of hypertension, hyperlipidemia, coronary artery disease treated with stents, severe right carotid disease treated with percutaneous interventions, lymphoma in remission, and previous chest radiation presented to our institution with severe aortic stenosis (valve area of 0.63 cm2). The patient was considered a poor candidate for traditional surgical aortic valve replacement because of his previous chest radiation and was scheduled for a TAVR. The case took place in a hybrid cardiac catheterization laboratory and operating room under general anesthesia with endotracheal intubation and monitoring with an arterial line, central venous access, pulmonary artery catheter, and transesophageal echocardiography (TEE). Because of the patient’s unfavorable iliofemoral anatomy, the surgeon selected a direct aortic approach through a right minithoracotomy. A 26-mm Edwards SAPIEN valve (Edwards Lifesciences Corporation, Irvine, CA) was deployed during rapid ventricular pacing. The valve’s position was then confirmed by the cardiologist performing TEE and the interventionalist through fluoroscopy. The patient remained hemodynamically stable throughout the procedure, requiring only small boluses of vasopressors during valve deployment and a transfusion of 200 mL of intraoperative cell-salvaged blood at the end of the case. Repeat TEE by the cardiac anesthesiologist during closure reconfirmed the cardiologist’s findings of normal biventricular function, good position of the new aortic valve, absence of paravalvular leaks, and absence of pericardial or pleural effusions. The patient was transported to the intensive care unit (ICU) for continued monitoring with his trachea intubated and a low-dose vasopressor infusion.
During the first hour in the ICU, the patient received 2 units of packed red blood cells for an initial hematocrit of 24 allowing for discontinuation of all vasopressor infusions. Over the next hour, the patient had increasing chest tube output, and the cardiothoracic surgeon was notified. Since the patient remained hemodynamically stable at this time, the critical care and surgical team opted to continue vigilant monitoring in the ICU. Shortly after this decision, as chest tube output continued to increase, the patient became acutely hypotensive with mean arterial blood pressure decreasing from the 80s to the 40s and a simultaneous increase in central venous pressure. Boluses and infusions of inotropes and vasopressors were required.
During this period, the cardiac anesthesiologist was called to assist the critical care and surgical team in further evaluation of the patient with suspicion of severe bleeding and cardiac tamponade. An emergent bedside TEE revealed right pleural effusion, pericardial effusion, and right atrial compression. The patient’s worsening hemodynamics and TEE findings prompted a joint decision by the surgeon, intensivist, and cardiac anesthesiologist to bring the patient immediately to the operating room for exploration. At the time of transport, the patient was receiving substantial doses of inotropes and vasopressors (epinephrine 0.3 µg/min, vasopressin 2.4 units/h, and norepinephrine 0.1 µg/kg/min).
Intraoperative TEE showed a large, right-sided pleural effusion and a pericardial effusion that was significantly larger than it had been in the previous ICU TEE examination (Figs. 1 and 2). Another large pericardial effusion with clot was seen pushing on the right atrium, causing discordant motion on the right side of the heart characteristic of cardiac tamponade, whereas the left ventricle was empty. Examining the replacement aortic valve revealed a competent valve with good flow and no paravalvular leak. During this time, aggressive resuscitation to maintain adequate arterial blood pressures continued, including IV fluid boluses, transfusion of multiple blood products, and vasopressor infusions with intermittent boluses.
The surgeon first explored the right minithoracotomy incision (site of direct aortic access for the TAVR), revealing right hemothorax and hemopericardium but no signs of bleeding from the aorta. Despite the patient’s prior chest radiation, the surgeon opted to proceed with a median sternotomy due to the necessity for further exploration. Fortunately, no difficulty was encountered during sternotomy, and several blood clots were evacuated from around the heart, revealing a perforation in the lateral wall of the left ventricle. Cardiopulmonary bypass was initiated, and the surgeon successfully repaired the defect. After drainage of the pericardial and pleural effusions and left ventricular repair, the patient’s hemodynamics significantly improved and all infusions were titrated down or discontinued. TEE showed no residual effusions and good biventricular function.
The patient was transported back to the ICU, where his trachea was extubated the next day. He was discharged home 7 days later.
As more patients present as candidates for TAVR, proceduralists continue to improve and develop a variety of devices and approaches to transcatheter insertion and valve deployment. In this case, cardiac tamponade developed after TAVR was used to place an Edwards SAPIEN valve through a transaortic approach. Initial exploration did not reveal direct aortic injury, but further exploration revealed perforation of the left ventricle. This perforation was attributed to injury from the guidewire used to position the valve during the initial TAVR procedure. This case highlights one potential complication of using the less common transaortic approach for TAVR.
It is important for anesthesiologists and other practitioners involved in the care of these patients to be aware of potential complications related to each of the approaches used for TAVR (Table 1).3–8 Intraoperative and postoperative complications require early identification and treatment to prevent significant morbidity and mortality. Signs revealed by various diagnostic modalities may assist with early diagnosis, such as ST changes on the electrocardiogram or wall-motion abnormalities on TEE exam reflecting ischemia from obstruction of a coronary artery, signs of vascular damage and hemorrhage on fluoroscopy or abdominal ultrasound, paravalvular aortic regurgitation on TEE exam, and focal deficits suggesting stroke on physical examination. It is clear from this short and nonexhaustive list that TAVR is not without risk.
Although this procedure may be less invasive than an open surgical valve replacement, all patients undergoing TAVR should be monitored in an ICU postoperatively just like those patients undergoing open surgical valve procedures. Complications may have a delayed presentation with potential catastrophic effects, requiring prompt identification and intervention by the intensivists, cardiologists, cardiac anesthesiologists, and surgeons. Communication among team members during this case expedited emergent exploration to identify the cause of life-threatening bleeding, ultimately leading to successful repair of the left ventricle laceration.
Teamwork and collaboration among the intensivist, surgeon, and cardiac anesthesiologist were necessary to achieve a favorable outcome for this patient. Similar to patients undergoing open surgical aortic valve replacement, patients undergoing TAVR require vigilant care by a multidisciplinary team that includes a cardiac anesthesiologist who is prepared to identify and manage all associated complications.
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7. Jilaihawi H, Chakravarty T, Weiss RE, Fontana GP, Forrester J, Makkar RR. Meta-analysis of complications in aortic valve replacement: comparison of Medtronic-Corevalve, Edwards-Sapien and surgical aortic valve replacement in 8,536 patients. Catheter Cardiovasc Interv. 2012;80:128–38
© 2014 International Anesthesia Research Society
8. Toggweiler S, Leipsic J, Binder RK, Freeman M, Barbanti M, Heijmen RH, Wood DA, Webb JG. Management of vascular access in transcatheter aortic valve replacement: part 1: basic anatomy, imaging, sheaths, wires, and access routes. JACC Cardiovasc Interv. 2013;6:643–53