2023 FSA Podium and Poster Abstracts

P007: TAVR AND THE TRAGIC SEQUENCE OF UNFORTUNATE EVENTS: CORONARY OCCLUSION, AORTIC DISSECTION, CARDIAC TAMPONADE, AND VASCULAR INJURY RESULTING IN MAJOR INTRA ABDOMINAL HEMORRHAGE.
Madina Akhmetkaliyeva, MD; Emily Chung, DO; Austin Smith, DO; Hani Murad, MD; HCA Florida Kendall Hospital

Introduction: Transcatheter Aortic Valve Replacement has emerged as a viable alternative to surgical aortic valve replacement for patients with severe symptomatic aortic stenosis. This is a case of a TAVR procedure that resulted in coronary artery occlusion, aortic dissection, cardiac tamponade, and vascular injury which all caused major intra-abdominal hemorrhage, and ultimately patient demise.

Methods: A 75-year-old female with a past medical history of hypertension and non-insulin-dependent diabetes mellitus presented for transcatheter aortic valve replacement for symptomatic aortic stenosis. The original anesthetic plan is Monitored Anesthesia care with dexmedetomidine and placement of a radial arterial line and two large bore IVs. The cardiac catheterization lab was prepared with all necessary equipment and medication in the event of emergent conversion to SAVR (surgical aortic valve replacement).

The interventional cardiologist established access through femoral vessels and was able to dilate the native stenotic valve with a balloon. On the deployment of the valve, the valve migrated cephalad, causing hemodynamic instability presumably from obstruction to coronary flow. The patient was immediately treated with crystalloid fluids and vasopressors as the cardiologist repositioned the valve away from the aortic sinus. The patient initially improved hemodynamically.

The decision was made to attempt to deploy a second prosthetic valve, using a valve-in-valve technique. The attempt was unsuccessful, leading to the patient becoming hemodynamically unstable with profound hypotension and hypoxia. At this point, the decision was made to convert to place the patient on cardiopulmonary bypass (CPB) and SAVR. The patient proceeded to go into cardiac arrest. Cardiopulmonary resuscitation was started as the cardiologist and cardiac surgeon attempted to cannulate for peripheral cardiopulmonary bypass. During the attempt, the left femoral vein was sheared, causing severe vascular injury. Once on bypass, SAVR was performed. Upon exposure, the surgeon discovered hemopericardium/cardiac tamponade, secondary to obvious aortic dissection. Peripheral cannulation was exchanged for central cannulation, as the vascular and trauma surgery team was called to repair the vascular injury. Groin exploration and exploratory laparotomy were ultimately performed in an attempt to control bleeding. Intraoperative findings included massive intraperitoneal and retroperitoneal hemorrhage.

Results: The aortic valve was replaced, femoral vessel was repaired, and the abdomen was packed. The patient was successfully weaned off of bypass; however, severe coagulopathy, acidosis, and vasoplegia were unable to be corrected, leading to hemodynamic compromise and ultimate collapse. Despite all interventions, the patient expired.

Discussion/Conclusion: Though TAVR is a promising treatment for a non-surgical candidate with severe aortic stenosis, there are potentially fatal complications associated with the procedure. This case highlights the rare but catastrophic complications, which include coronary occlusion, aortic dissection, cardiac tamponade, and vascular injury resulting in major intra-abdominal hemorrhage. The importance of careful candidate selection, operator expertise, and timely recognition and management of complications cannot be overstated in ensuring the safety and success of the procedure.