CASE20250514_003
A Novel Method to Manage Annular Rupture with Cardiac Tamponade During Transcatheter Aortic Valve Replacement
By Tomonari Moriizumi, Kei kamata, Ryo Arita, juri iwata, Toshinobu Ryuzaki, Kentaro Hayashida
Presenter
Tomonari Moriizumi
Authors
Tomonari Moriizumi1, Kei kamata1, Ryo Arita1, juri iwata1, Toshinobu Ryuzaki1, Kentaro Hayashida1
Affiliation
Keio University Hospital, Japan1,
View Study Report
CASE20250514_003
TAVR - Complex TAVR
A Novel Method to Manage Annular Rupture with Cardiac Tamponade During Transcatheter Aortic Valve Replacement
Tomonari Moriizumi1, Kei kamata1, Ryo Arita1, juri iwata1, Toshinobu Ryuzaki1, Kentaro Hayashida1
Keio University Hospital, Japan1,
Clinical Information
Relevant Clinical History and Physical Exam
A 94-year-old woman presented with exertional dyspnea classified as NYHA class III. Her medical history included paroxysmal atrial fibrillation but was otherwise unremarkable. She required 1 L/min of supplemental oxygen to maintain oxygen saturation. Vital signs were stable. Physical examination revealed a Levine grade 3/6 systolic ejection murmur at the second right intercostal space. There were no signs of volume overload, including jugular venous distension or peripheral edema.
kitamuraTTE3.mp4
kitamuraTTE3.mp4Relevant Test Results Prior to Catheterization
Laboratory tests showed a mildly elevated B-type natriuretic peptide (BNP) level of 225.0 pg/mL. Chest X-ray revealed no pleural effusion but demonstrated cardiomegaly and mild pulmonary congestion. Transthoracic echocardiography identified very severe aortic stenosis with markedly reduced valve area and elevated transvalvular gradients. Multidetector computed tomography (MDCT) revealed a small aortic annular area measuring 346 mm² and severe leaflet calcification, especially at the NCC.
Relevant Catheterization Findings
Interventional Management
Procedural Step
Given the patient’s advanced age and high surgical risk, transfemoral TAVR was performed under local anesthesia. Pre-dilatation with a 20-mm balloon ruptured due to severe calcification, causing sudden hemodynamic collapse. Urgent implantation of a 23-mm SAPIEN 3 Ultra RESILIA valve was done, but hypotension persisted.
Echocardiography showed a large pericardial effusion indicating cardiac tamponade. The patient was intubated, and subxiphoid pericardiocentesis drained hemorrhagic fluid, temporarily improving blood pressure. Emergency surgery was not possible due to frailty.
A closed-loop circuit connecting the pericardial drain to a 10Fr sheath was established for autotransfusion. Transesophageal echocardiography confirmed annular rupture. Blood pressure was kept below 80 mmHg to prevent re-rupture, and protamine was withheld to allow drainage. After 30 minutes, the patient stabilized.
Postoperative CT revealed a limited aortic dissection. Blood pressure was tightly controlled and gradually raised. The closed-loop circuit was stopped on day 2, with drainage decreasing and hemoglobin stable. CT on day 7 showed no worsening. The drain was removed, and the patient recovered without surgery.
Case Summary
This case demonstrates that conservative management, combining tight blood pressure control, continuous autotransfusion achieved via a closed-loop pericardial drainage system, can effectively stabilize aortic annular rupture during TAVR in selected high-risk, inoperative patients. This immediately implementable approach may serve as a practical bailout strategy, potentially avoiding the need for emergency surgery and improving outcomes in patients.