In the treatment of severe aortic stenosis, transcatheter aortic valve replacement (TAVR) procedure is increasingly being used. In this report, we present a case of balloon rupture during TAVR operation, followed by successful valve implantation, with appropriate management of complication.
Case Report
An 88-year-old male was admitted to our clinic with complaint of effort dyspnea. Transthoracic echocardiography revealed severe aortic stenosis. The Society of Thoracic Surgery (STS) risk score was calculated to determine the risk of surgery, and then the patient with 6 STS point had decided to undergo TAVR operation by the heart team. In the preoperative preparation phase, valvular annulus and aortic–iliac vessels could not be evaluated using computed tomography (CT) due to high creatinine levels. Therefore, the diameter of the aortic annulus measured using transesophageal echocardiography (TEE) was found to be 26 mm. The Edwards Sapien S3 valve (Edwards Lifesciences Inc., Irvine California, USA) was selected for implantation, because the main femoral arteries were observed to be 6 mm in diameter and calcified by iliac digital subtraction angiography. Additionally, aortic root angiography was performed prior to the procedure; the ascending aorta was found to be horizontal, whereas the descending aorta was distinctly tortuous and locally calcified. With the standard TAVR procedure, a Safari-2 guidewire was placed in the left ventricle. Predilatation was performed with a 25×40 mm balloon by the Safari-2 guidewire. Then, the 29 mm valve was loaded into the delivery system, and the valve started to move from the right femoral artery. The valve was difficult to load into the vessel due to the lack of complete coaxiality after the sheath was removed. After seeing that the valve was brought to the proper position (Video 1), the balloon with valve was tried to inflate for implantation but we could not, so the valve could not be opened, at that moment some blood came out from the system when negative pressure was applied. After this, we thought that the balloon exploded, and the valve was taken back into the delivery system. The Safari-2 guidewire was just left in the ventricle, but the entire system was pulled back together with the sheath. The valve that was pulled back with the other system was checked; no structural or functional problem was found (Fig. 1). Then the same valve was loaded into a new delivery system from the same femoral artery but at another puncture place. Fortunately, the valve system was successfully implanted (Video 2). Paravalvular insufficiency was not observed during the control aortography (Video 3).
Figure 1
The balloon burst when the delivery system was withdrawn
The balloon burst when the delivery system was withdrawn
Discussion
To the best of our knowledge, this is the first study to report such a complication; during the process, the balloon burst without being inflated. The rupture may have been caused by the fact that the valve–balloon axis was different during the loading of the valve into the balloon.In literature, the number of cases reporting balloon rupture during TAVR operation is limited (1-3). Cases of balloon rupture associated with aortic valve have been reported mostly during aortic balloon valvuloplasty in the preoperative period. In these reports, balloon rupture development has been associated with the presence of a bicuspid aortic valve, sudden high-pressure inflation of the balloon, or intense calcification in the ascending aorta (4, 5). In literature, we could not find any case in which the balloon was ruptured without being inflated during the TAVR operation, similar to our case.The preoperative preparations are extremely important to foresee the complications that may occur during the TAVR operation. At this stage, evaluation of the calcification and tortuosity of the ascending and descending aorta as well as the detailed evaluation of the valve with TEE and CT is extremely important. In the presence of advanced aortic tortuosity, a harder wire may be helpful in solving the problem. Alternatively, subclavian or aortic pathway may be preferred.There are some prosthetic valves that can be retrievable or not during the TAVR operation. The Edwards Sapien S3 valve is not repositionable or retrievable, making precise deployment critical. However, it can be reused when it is withdrawn before inflation. In our patient, the balloon never inflated, thus the valve never opened.
Conclusion
Although TAVR opens new horizons in the treatment of patients with severe aortic stenosis, it has brought new complications too. However, in these cases, successful implantation of the same valve is possible with timely detection and correct management of complications.
Video 1
After the bioprosthesis valve was adjusted to the proper position, the balloon was tried to inflate with opaque saline injection; however, it did not inflate.
Video 2
The re-installed valve was successfully implanted.
Video 3
There were no paravalvular insufficiencies in control aortography after the valve implantation.
Figure 1