Endovascular entry closure of a late type A aortic dissection after implantation of a self-expanding transcatheter heart valve (Evolut R): a case report

Abstract

Background: Late Stanford type A aortic dissections (TAADs) are a very rare complication after transcatheter aortic valve implantation (TAVI). Surgery is the treatment of choice, but perioperative mortality (25%) and neurological complications (18%) remain high.

Case summary: An 85-year-old male patient presented with acute chest pain 5 months after a transfemoral Evolut R 34 mm transcatheter heart valve (THV) implantation. On multi-slice computed tomography (MSCT) a TAAD was found with a 7 mm primary entry at the supra-annular aortic edge of the THV expanding to the innominate artery without re-entry. Due to extensive comorbidities including two bypass operations in the history, the Heart Team declined surgery. Within 6 months of watchful waiting the maximal aortic diameter (MAD) increased from 57 to 62 mm. The decision was made to perform an endovascular closure of the inflow to the false lumen by implanting a 25 mm Amplatzer™ Cribriform Septal Occluder. MSCT 4 weeks after occlusion showed the false lumen almost completely filled with thrombus, MSCT 3 months later showed a MAD reduction to 55 mm with shrinkage of the false lumen.

Discussion: Presumably, the late TAAD was caused by the supra-annular edge of the Evolut-stent. Because of the extreme risk surgical repair was not an option and a stent graft would have occluded the vein grafts. This case shows that in absence of any other treatment options endovascular closure of the entry to the false lumen can be successfully performed in a TAAD after TAVI.

Keywords: Case report; Self-expanding transcatheter heart valve; Stanford type A aortic dissection; TAVI.

Figure 1

(A) Multi-slice computed tomography of the calcified aortic valve and a normal-sized ascending aorta before transcatheter aortic valve implantation (arrow). (B) Arrowheads indicate the ostia of the patent vein grafts to right coronary artery and left circumflex artery.

Figure 2

Final root shot revealed a small paravalvular leak with mild aortic regurgitation and without pathological findings of the ascending aorta.

Figure 3

Multi-slice computed tomography of the type A aortic dissection. Arrowhead indicates the primary tear (7 mm) at the supra-annular aortic edge of the transcatheter heart valve (*). Arrow indicates the perfused false lumen with a small thrombus formation in the upper part.

Figure 4

Step-by-step endovascular entry closure of a late type A aortic dissection after transcatheter heart valve implantation with an Amplatzer Cribriform PFO Occluder.

Figure 5

(A–C) Multi-slice computed tomography 4 weeks after endovascular entry closure. Arrow indicates the false lumen now filled with thrombus. Arrowhead indicates a small residual perfusion. The aortic diameter is unchanged. (C) Three-dimensional reconstruction showing the Occluder fixed at the supra-annular nitinol frame of the Evolut valve. (D and E) Multi-slice computed tomography 12 weeks after endovascular closure. Arrow indicates the false lumen filled with thrombus. Arrowhead indicates the residual perfused lumen now reduced by half. The diameter of the aorta is reduced by 7–55 mm due to thrombus shrinkage.