Background
A 70 female with history of severe aortic stenosis (s/p trans catheter aortic valve replacement 18 months prior) was transferred to our facility from an outside hospital in acute cardiogenic shock. Co-morbidities were significant for end-stage renal disease on hemodialysis, coronary artery disease, and hypertension. Following progressive shortness of breath for 4 months, she was admitted for NSTEMI treated with angioplasty & initiation of temporary support with an intra-aortic balloon pump and inotropes at the outside facility. Trans-esophageal echocardiogram demonstrated severe stenosis of existing bioprosthetic valve (0.6 cm2), low normal ventricular ejection fracture, and moderate mitral regurgitation. Following transfer, the patient also developed coffee-ground emesis with worsening hypotension requiring blood transfusion, initiation of norepinephrine, and continuous renal replacement therapy.
Case
In the procedure suite, the patient was intubated with a rapid sequence technique. New central venous access and invasive arterial monitoring lines were established. Upper endoscopy demonstrated esophageal ulceration and a bleeding arteriovenous malformation in the stomach, which was clipped. The trans-esophageal echocardiogram probe was passed without difficulty. Under fluoroscopy, a new bioprosthetic valve was then deployed within the existing bioprosthetic valve. There was an immediate improvement in hemodynamics allowing removal of the intra-aortic balloon pump and rapid weaning of inotropic infusions.
Discussion
Hemodynamic instability at the time of TAVR is associated with increased mortality, but the mortality is lower than emergent surgical aortic valve replacement or valvuloplasty. In a patient who is not a candidate for either of the latter interventions, TAVR can be a life-saving intervention.
Valve-in-valve TAVR is a recent intervention for degenerative valves, with feasibility studies performed in 2007 and FDA approval granted in 2015. TAVR registries have shown a median time to valve degeneration of approximately 9 years. Stenosis is more common (42%) compared to regurgitation (34%), with the remaining (24%) developing both pathologies. One-year all-cause mortality is 13.4% (8.9% due to cardiac pathology). Stenosis is associated with a lower survival rate compared to regurgitation (76% versus 91%).
