Successful Transcatheter Aortic Valve Implantation in a High-Risk Elderly Patient with Intraoperative Ventricular Tachycardia: A Case Report

ABSTRACT

Aortic stenosis (AS) is a common valvular heart disorder in older adults, primarily caused by age-related degenerative changes. In high-risk cases, transcatheter aortic valve implantation (TAVI) has emerged as a viable and less invasive alternative to surgical aortic valve replacement for patients with symptomatic severe AS and an elevated risk of operative mortality. We report a favorable outcome of TAVI performed under monitored anesthesia care in a 76-year-old woman with multiple comorbidities who developed ventricular tachycardia during the procedure conducted under local anesthesia with light sedation.

INTRODUCTION

Aortic stenosis (AS) is a frequent form of valvular heart disorder in older adults, primarily resulting from age-related degenerative changes.[1] A combined analysis of seven studies (n = 9723) reported a pooled prevalence of AS in individuals aged 75 years and above to be 12.4% (95% confidence interval: 6.6%–18.2%).[2] At present, there are no extensive population-based investigations from India that specifically quantify the prevalence of AS in those aged ≥75 years. Epidemiological data tailored to this age group within the Indian population remain limited or unavailable.[3] Although surgical aortic valve replacement (SAVR) has traditionally been the standard therapy for individuals with severe symptomatic AS, its use in older adults remains debatable, particularly because perioperative mortality can reach up to 10% in patients over 90 years of age.[4] In such high-risk cases, transcatheter aortic valve implantation (TAVI) has emerged as a viable and less invasive alternative to SAVR for patients with symptomatic severe AS and an elevated risk of operative mortality.[4] According to the 2017 focused update of the American Heart Association and the American College of Cardiology guidelines, TAVI carries a Class I recommendation for treating severe symptomatic AS in individuals deemed high risk for surgical intervention.[5] The authors of this report present a favorable outcome of TAVI performed under monitored anesthesia care in a 76-year-old female patient from India.

CASE REPORT

A 76-year-old woman was admitted to a tertiary care hospital in Pune with worsening dyspnea due to severe AS. Her medical history included systemic hypertension, chronic obstructive pulmonary disease (COPD), interstitial lung disease, ischemic heart disease, and hypothyroidism. Her left anterior descending (LAD) artery stenting was performed in 2009. The patient had a history of petechiae following heparin use during her angioplasty in 2009. On examination, she was thin to moderately built, anemic, with a blood pressure (BP) of 130/80 mmHg, a pulse of 82/min, and a room air SpO₂ of 95%. The electrocardiography showed right bundle branch block and left ventricular hypertrophy (LVH). Echocardiography revealed mild concentric LVH, severe AS (valve area 0.51 cm², mean gradient 52 mmHg, peak gradient 83 mmHg), a thickened, heavily calcified valve, left ventricular ejection fraction 60%, grade 2 diastolic dysfunction, and pulmonary artery systolic pressure of 22 mmHg. Computed tomography (CT) aortography was done as part of the routine TAVI assessment. The CT aortography confirmed a tricuspid, calcified valve, concentric LVH, patent LAD artery stent, and mild calcific disease in the left circumflex artery and right coronary artery. She was classified as New York Heart Association class III. The patient and family consented to TAVI. A multidisciplinary team did preoperative assessments. Standard antibiotic prophylaxis was administered. Under standard monitoring and light sedation (intravenous [IV] midazolam 1 mg), large-bore IV access and an intra-arterial line were placed. Hydrocortisone 100 mg and nebulization were given preprocedure. Monitors included 5-lead electrocardiography (ECG), pulse oximetry, external defibrillator pads, invasive BP, and urine output. Oxygen was delivered via a Hudson mask at 4 L/min.

Femoral access was obtained under local anesthesia. IV fentanyl 50 μg was given for sedation. Heparin (1 mg/kg) was administered to maintain an activated clotting time >250 s. Balloon aortic valvuloplasty was performed under rapid ventricular pacing (RVP) [Figure 1] at 180 bpm, followed by valve deployment during a second RVP. Immediately after deployment, the patient developed ventricular tachycardia (VT) [Figure 2], which reverted with direct current (DC) shock (200J). A second VT episode was also reversed with DC shock. The episodes of VT were hemodynamically unstable, though a pulse was present, so synchronized cardioversion was delivered at 200 J. Other resuscitation measures, including IV lignocaine (90 mg) and amiodarone infusion (300 mg), were initiated, and an intubation tray was kept ready in case intubation became necessary. However, the patient remained completely stable after the DC shock.

Figure 1.

Rapid ventricular pacing

Figure 2.

Ventricular tachycardia

Postconversion, she developed transient left bundle branch block that spontaneously returned to sinus rhythm. Heparin was reversed with protamine. Figure 3 shows the TAVI valve and the fluoroscopic image after deployment. Postdeployment echocardiography showed a well-functioning valve with a peak gradient of 16 mmHg. The patient did not develop petechiae during the TAVI procedure, and the platelet count after the procedure was normal. The patient was monitored in the cardiac surgery intensive care unit and discharged on postoperative day 3. She remained clinically stable at 30-day follow-up.

Figure 3.

Transcatheter aortic valve implantation valve

DISCUSSION

The transcatheter approach to the aortic valve can be performed via either an antegrade (transapical approach) or a retrograde route, such as the transfemoral approach, as well as other transarterial approaches (e.g., through the subclavian, axillary, iliac, transbrachial, or radial arteries).[1] In our patient, transfemoral TAVI was used, which represents the standard approach. Regarding the preoperative evaluation of TAVI patients, particular attention should be paid to factors known to predict a high risk of intraprocedural instability, such as impaired ventricular function, pulmonary hypertension, significant mitral or tricuspid regurgitation, significant coronary artery disease, COPD, and kidney disease.[1]

TAVI must be performed under strict sterile conditions in a cardiac catheterization laboratory (cath lab) or hybrid operating room. In our case, the procedure was performed in a cath lab with cardiac surgical backup available in the hospital. Standard antibiotic prophylaxis for valve surgery should be administered per local protocol. Intraprocedural monitoring should include standard measures such as five-lead ECG, pulse oximetry, invasive arterial BP monitoring, central venous pressure monitoring, and urine output assessment. Pulmonary artery catheterization is not routinely used but may be indicated in specific cases, such as patients with left ventricular dysfunction and/or pulmonary hypertension.[2] Maintaining hemodynamic stability is the primary objective of anesthetic management during TAVI.

The most important anesthetic consideration in TAVI is the choice of anesthesia technique. Both general anesthesia (GA) and local anesthesia (with or without sedation) have been used for transfemoral and transaxillary TAVI. Practices vary across hospitals and countries, and the decision depends on multiple factors, including patient characteristics, procedural requirements, and logistical considerations. In the early years of TAVI, GA was the standard approach. The specific anesthetic agent used is less critical than its administration, which should be slow and carefully titrated to effect.[2] Short-acting agents are preferred to facilitate rapid emergence and extubation at the end of the procedure. In our patient, we employed local anesthesia with light sedation.

Sedation alone during the procedure helps avoid the hemodynamic fluctuations commonly associated with the induction of GA, facilitates early recognition of neurological complications in an awake patient, and is associated with reduced procedural and recovery times. However, when local anesthesia with sedation is used, the anesthesiologist must remain prepared to convert to GA if necessary. In the present case, following the procedure, the patient was transferred to the cardiac surgery intensive care unit for 24-h monitoring. Initial postprocedural care in a critical care setting—either a surgical or coronary intensive care unit—is essential. Continuous monitoring of hemodynamics, vascular access sites, cardiac rhythm (with particular attention to delayed atrioventricular block), and renal function is required.

Following GA, it is recommended that patients be extubated in the interventional room and subsequently transferred to the postanesthesia care unit or intensive care unit. Postoperative pain is typically well controlled using nonsteroidal anti-inflammatory drugs, paracetamol, and low-dose opioids. In patients with atrioventricular block, a temporary pacemaker is commonly placed to prevent cardiac arrest. In our case, as per current guidelines, dual antiplatelet therapy was continued with aspirin (75–100 mg daily) and clopidogrel (75 mg daily) for 6 months. Excluding an anesthesiologist from TAVI procedures to save time or reduce costs is not aligned with standard practice and should be carefully reconsidered, especially when driven by financial motives.

CONCLUSIONS

TAVI provided a successful treatment for severe AS in this high-risk elderly patient, with prompt management of intraoperative VT, ensuring a favorable outcome. Careful planning, teamwork, and swift complication management were key to the positive result.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.