JACC

Lots of interesting abstracts and cases were submitted for TCTAP 2021 Virtual. Below are accepted ones after thoroughly reviewed by our official reviewers. Don’t miss the opportunity to explore your knowledge and interact with authors as well as virtual participants by sharing your opinion!

TCTAP C-111 . Presentation

Presenter

Faizal Khan Abdullah

Authors

Faizal Khan Abdullah1, Shaiful Azmi Yahaya1, Kumara Gurupparan Ganesan1, Jayakhanthan Kolanthaivelu1, Wan Faizal Bin Wan Rahimi Shah1, Afif Ashari1, Faten Aqilah Binti Aris1

Affiliation

National Heart Institute, Malaysia1,
View Study Report
TCTAP C-111
STRUCTURAL HEART DISEASE - Valvular Intervention: Aortic

Calcified Descending Aortic Dissection During TAVI

Faizal Khan Abdullah1, Shaiful Azmi Yahaya1, Kumara Gurupparan Ganesan1, Jayakhanthan Kolanthaivelu1, Wan Faizal Bin Wan Rahimi Shah1, Afif Ashari1, Faten Aqilah Binti Aris1

National Heart Institute, Malaysia1,

Clinical Information

Patient initials or Identifier Number

KHH

Relevant Clinical History and Physical Exam

76 year old /FemaleKnown IHD 2000CABG performed x3 SVGRecurrent admission for Acute pulmonary edemaNo chest painNo syncope
On ExaminationBP 165/86HR 78CVS: Ejection Systolic murmur radiating to carotid

Relevant Test Results Prior to Catheterization

Echocardiogram: Left ventricular ejection fraction 62%, mildly dilated left atrium, severe aortic stenosis with AVA 0.66cm, mean PG: 51mmHgMax PG: 91mmHgMild Aortic regurgitation
ECG: Sinus rhythm
echo.mpg

Relevant Catheterization Findings

Graft Study: All grafts patentBilateral iliac artery calcification, left iliac worse calcificationRight iliac ostium size: 4.7 mm x 9.2 mm, 2 point calcificationLeft iliac ostium size: 3.7 mm x 7.5 mmDistal aorta calcification: Lumen size 7.7 mm x 7.9mm, calcification


Interventional Management

Procedural Step

Bilateral femoral puncture with 6F sheath. Preclosed with 2x proglide on right femoral.Upgraded right femoral 6F sheath (device location) to 12Fsheath. While trying advance dilator of 14F sheath, we were unable to progress further beyond right common iliac to distal aorta due to severe calcification. Noted the calcium piece moves on manoeuvre.Decided to predilate right common iliac artery and distal aorta with peripheral balloon 5.0 x 20 above nominal pressure.When trying to advance the main device Corevalve Evolut R 23mm noted still hitting the calcium at distal aorta.On trying to push the device further noted there were give away of TAVI device as it moves forward and the whole piece moves together with the device.Immediately, pulled back device and taken angiogram shot from pigtail. Noted descending aortic dissection below the renal arteries. However, it was non flow limiting.Decided to predilate distal aorta with 6.0 x 40 balloon. Following that manage to cross the device and deployed TAVR successfully.Before ending procedure, angiogram shot taken showed no worsening in size of dissection. Decided for conservative management with plan to repeat CT angiogram later.
TAVI sheath cant go in.mpg
Calcium dissect.mpg
post dissect.mpg

Case Summary

Aorta calcification is commonly seen especially in the elderly where the most common age group TAVI being performed. In this case, there is a severe calcification at distal aorta which was underestimated. Though the initial report showed there is enough space for the TAVI device to go through, the extent of calcium was extensive that it didn't allow the device to go through despite of predilatation.Pushing any large device across a severe calcification need to be made carefully as stripping of calcium could lead to life-threatening aorta perforation. In this case, we were fortunate that calcium stripping only caused non flow limiting dissection. 

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TCTAP 2021 Virtual Apr 12, 2021
Thanks for sharing your report. It’s very helpful for us.