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Case Reports
. 2020 Oct 21;2(12):1852-1858.
doi: 10.1016/j.jaccas.2020.09.007. eCollection 2020 Oct.

Percutaneous Management of a Contained Annular Rupture Occurring With Self-Expanding Transcatheter Aortic Valve Replacement

Morgan S Kellogg  1 , Mark K Tuttle  1 , Ravi K Sharma  1 , Sahil V Mehta  1 , Roger J Laham  1
Affiliations
Case Reports

Percutaneous Management of a Contained Annular Rupture Occurring With Self-Expanding Transcatheter Aortic Valve Replacement

Morgan S Kellogg et al. JACC Case Rep. .

Abstract

Annular rupture is a rare catastrophic event during transcatheter aortic valve replacement, often life threatening and requiring emergent surgical repair. We describe, herein, a case of contained annular rupture successfully managed percutaneously with coiling and polymer injection. This is a novel technique to manage this complication. (Level of Difficulty: Advanced.).

Keywords: CT, computed tomography; Evolut; LVOT, left ventricular outflow tract; POD, post-operative day; TAVR; TAVR, transcatheter aortic valve replacement; annular rupture; coiling.

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Conflict of interest statement

Dr. Laham has served as a consultant for Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

None
Graphical abstract
Figure 1
Figure 1
Pre-Procedure Electrocardiogram-Gated Multiplanar Computed Tomography Aortography Demonstrating a Moderately Calcified Bicuspid Aortic Valve LC = left coronary cusp; NC = non-coronary cusp; RC = right coronary cusp.
Figure 2
Figure 2
Aortography After Post-Dilation Aortography after post dilation demonstrating a well-expanded valve frame with patent right coronary artery (A), left main coronary artery (B), and an area of contrast extending outside of the valve frame consistent with contained annular rupture (arrow).
Figure 3
Figure 3
Computed Tomography Images of Contained Annular Rupture Computed tomography images of aortic valve showing a contained outpouching (A) at the inferior aspect of the valve cage below the right coronary artery (B). The arrows point to the “contained outpouching.”
Figure 4
Figure 4
Fluoroscopic Images of Annular Rupture Repair Procedure (A) Right coronary angiography. (B) Aortic root angiograph did not demonstrate the outpouching (C) Infra-annular ventriculography of the LVOT from within the Evolut Pro + valve frame did not demonstrate the expected outpouching below the right coronary artery secondary to the skirt, which surrounds the valve cage below the neoannulus. (D) left anterior oblique projection demonstrating the tip of the Simmons 1 catheter behind the valve frame at a location under the left main coronary artery, the only place it could be stably positioned behind the valve frame. From the catheter, a Prowler Plus microcatheter (Johnson & Johnson, New Brunswick, New Jersey) guided by Choice PT Extra Support coronary guidewire (Boston Scientific, Marlborough, Massachusetts) is advanced anteriorly around the outside of the valve frame and directed toward the expected location of the outpouching. Contrast injections through the microcatheter were able to fill the outpouching. (E) The first of 4 nylon-fibered helical Concerto coils (Medtronic, Minneapolis, Minnesota) is delivered to the contained rupture. (F) Final result after coiling and injection of Onyx LD ethylene-vinyl alcohol copolymer glue (Medtronic).
Central Illustration
Central Illustration
Percutaneous Repair of a Contained Annular Rupture Pre-procedure: Diagram and fluoroscopic image demonstrate an outpouching in the aortic root (arrows) representing a contained annular rupture. Post-Procedure: Diagram and fluoroscopic image demonstrate successful repair of the contained annular rupture and exclusion from the aorta using coil placement and polymer injection.
See this image and copyright information in PMC

References

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