Transapical aortic valve replacement complicated by periaortic hematoma

Abstract

A 77-year-old woman with severe symptomatic aortic stenosis (aortic valve areaZ0.6 cm2 and mean gradientZ 53 mmHg) was deemed inoperable for surgical aortic valve replacement due to a porcelain aorta, and was scheduled for transcatheter aortic valve replacement via an apical approach. A 23 mm valve was selected based on a computerized axial tomographic angiography derived area of 360 mm²; valve oversizing was 15.4%. Baseline transesophageal echocardiography revealed severe protruding atheroma within the lumen of the ascending aorta. Immediately following deployment of the Sapien pericardial tissue valve (Edwards Life Sciences, Irvine, CA, USA), a large posterior periaortic hematoma was noted (1.3 cm in maximum width, and w4 cm in length) (see Fig. 1 and Videos 1, 2, 3, 4). Protamine was administered, and the hematoma was observed by transesophegeal echocardiography for w30 min with no change in size; function of the bioprosthetic valve was normal without regurgitation. In the immediate post-operative period, anti-platelet agents were withheld, and blood pressure was aggressively lowered. The remainder of her hospital course was uncomplicated, and a tranthoracic echocardiogram w1 month later demonstrated resolution of the hematoma. Periaortic hematoma and aortic root rupture are recognized potential major complications of transcatheter aortic valve replacement (1, 2). Severe left ventricular outflow tract calcification and annular over sizing are both risk factors for these complications. Careful transesophageal echocardiographic examination post valve deployment may lead to early recognition and treatment of this potentially fatal complication (3). In this case, presence of severe protruding atherosclerotic plaque pre-procedure likely predisposed to this complication.