Conservative approach of ascending aortic dissection after transcatheter aortic valve replacement: A case report

Abstract

Transcatheter aortic valve replacement (TAVR) has shown good early and midterm results from high risk to low surgical risk patients with severe symptomatic aortic valve stenosis. Despite low adverse events, TAVR is associated with vascular injury, bleeding, stroke, and conduction system disturbances as the most common adverse events. Aortic dissection is a relatively rare but potentially lethal complication from TAVR. Here, we report a case of ascending aortic dissection (type A) complicating TAVR that was managed conservatively with complete resolution of the complication noted on serial computed tomography angiogram.

Case presentation

An 80-year-old female with a history of severe aortic stenosis presented with progressive dyspnea on exertion. The patient has history hypertension, paroxysmal atrial fibrillation, hypercoagulable state due to genetic mutation of prothrombin with multiple episodes of pulmonary embolisms treated with anticoagulation for which she is on chronic Rivaroxaban therapy. Transthoracic echocardiogram showed a tricuspid aortic valve area of 0.8 cm, mean gradient of 42 mmHg consistent with severe aortic valve stenosis.

Computed tomography angiogram (CT-A) TAVR revealed a severely restricted aortic valve with significant calcification of the ascending aorta, including the sinotubular junction with calcium protruding to the aortic lumen more prominent in the outer curvature (Fig. 1). The calcium score for the aortic valve was 1059 HU. The procedure was performed under moderate sedation using a femoral access, a 26 mm Evolut FX Valve ™ was used for the procedure as per the patient TAVR-CTA measurements, overall the procedure was uneventful, but while passing the valve catheter through the ascending aorta outer curvature mild resistance was noted but it was easily overcome with changing angulation and mild forward push. TTE showed no regurgitation, and the mean gradient was 5 mmHg. The patient had an unremarkable hospital stay: she was discharged home after 2 days and Rivaroxaban was restarted the day after the procedure.

Fig. 1.

Pre TAVR CT-A showing areas of severe calcification in the aorta outer curvature.

One week postoperative, the patient arrived at the ER with symptoms suggestive of pneumonia so chest CT was performed (Fig. 2). Incidentally aortic dissection starting above the right coronary sinus and extending to above the aortic arch was noted (it did not involve the arch branches) (Fig. 3). After heart team discussion the decision was to proceed with conservative management reversion rivaroxaban with Feiba, and tight blood pressure control in ICU with close monitoring since the patient was considered not to be a surgical candidate.

Fig. 2.

Alveolointersticial infiltrates with bilateral mosaicism in relation to pneumonia.

Fig. 3.

(A) Sagittal view of post-TAVR changes, intramural hematoma in relation to aortic dissection. (B) Axial view of post-TAVR changes, intramural hematoma in relation to aortic dissection.

During the initial treatment, minimal changes in the aortic dissection were observed on serial CT-As, with the patient being asymptomatic and maintaining appropriate blood pressures; she was discharged home after 5 days in the hospital and anticoagulation was held for a total of 2 weeks. Two weeks after resuming anticoagulation the patient remained asymptomatic, a follow-up CT scan shows a considerable increase in the aortic dissection (Fig. 4), leading to the decision to discontinue anticoagulation indefinitely.

Fig. 4.

Axial view showing an increase in mural hematoma related to aortic dissection following the initiation of anticoagulant therapy.

The patient continues with strict blood pressure control. Subsequently follow-up CT scans showed stable findings that later improved to a complete healing and resolution of dissection 4 months after (Fig. 5, Fig. 6).

Fig. 5.

(A) Sagittal view of improvement of the aortic dissection after discontinuation of anticoagulant. (B and C) Axial view of improvement of the aortic dissection after discontinuation of anticoagulant.

Fig. 6.

(A and B) Axial view of lumen of thrombosed aortic dissection with progressively resorption, with intact true lumen. (C and D) Axial and sagittal view of complete resorption of the false lumen with resolution of the aortic dissection.

Discussion

According to the European Society of Cardiology (ESC), patients with severe aortic stenosis older than 75 years with high risk for open surgery (STS PROM/EuroSCORE II greater than 8%) are candidates for TAVR compared to surgical aortic valve replacement (SAVR) [1]. Although it is a safer procedure, there is also a risk of complications.

Aortic dissection as a complication of transcatheter aortic valve replacement is a rare event; an incidence of up to 1.9% has been reported in the literature [2]. Among the risk factors for post-TAVR aortic dissection, we have those that are inherent to the patient such as advanced age, female sex, atherosclerosis, aortic wall weakening (secondary to steroid or immunomodulator use) [3] and those inherent to the procedure such as aggressive balloon valvuloplasty, difficult placement of the artificial valve in position and large size of the transcatheter valve [4].

ESC guidelines on aortic pathology describe that treatment of iatrogenic aortic dissection is usually conservative [5], but to date, there are no evidence-based guidelines on the appropriate management of aortic dissection following TAVR, thus, each patient must be individualized according to his or her history, clinical condition, and prognosis in order to choose between surgery or conservative treatment.

Medical management is based on blood pressure and heart rate control with close follow-up and it is frequently chosen in uncomplicated dissections. But in case of imminent rupture, uncontrolled pain or inadequate perfusion, either endovascular or open surgical management should be considered [6].

To our knowledge this is the first case reported of the evolution of an iatrogenic ascending aortic dissection from the onset to the complete resolution. The mechanism of spontaneous resolution remains unclear. In our case, probably with the suspension of anticoagulant therapy, the intramural hematoma thrombosed, stabilized and reabsorbed, resulting in resolution of the dissection.

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