CR3. A Perfect Storm During Valve-in-Valve TAVR: Coronary Occlusion, Device Migration, Surgical Rescue and Advanced Mechanical Circulatory Support

We report the case of a 75-year-old woman with prior aortic valve replacement using a stentless prosthesis, referred for severe prosthetic regurgitation and deemed at prohibitive risk for redo surgery. She underwent percutaneous valve-in-valve transcatheter aortic valve replacement with a self-expandable prosthesis. Immediately after valve deployment, acute left main coronary artery occlusion resulted in cardiac arrest. During attempted coronary intervention, the transcatheter valve migrated into the ascending aorta, and a second valve implantation attempt using a balloon-expandable prosthesis failed due to balloon rupture (image). Following multidisciplinary Heart Team discussion, the patient was emergently transferred to the operating room.
Shortly after resternotomy, the patient suffered a second cardiac arrest requiring immediate central cardiopulmonary bypass. Given hemodynamic collapse and the position of the migrated transcatheter valve, brief hypothermic circulatory arrest was employed to allow safe valve retrieval and direct inspection of the ascending aorta, followed by explantation of the degenerated stentless prosthesis and implantation of a new surgical valve. Inability to wean from cardiopulmonary bypass despite maximal pharmacologic support necessitated initiation of venoarterial extracorporeal membrane oxygenation.
Intraoperative transesophageal echocardiography revealed severe acute right ventricular dysfunction not present preoperatively, raising strong suspicion of right coronary artery compromise and prompting urgent coronary artery bypass grafting, with immediate hemodynamic improvement. Ongoing refractory cardiogenic shock required escalation to additional left ventricular unloading with an Impella device.
Within one week, the patient demonstrated recovery of biventricular function and was successfully weaned from all mechanical circulatory support. Postoperative echocardiography showed excellent prosthetic valve function, and the patient was discharged home after a short period of rehabilitation.
This case highlights the lethality of catastrophic valve-in-valve TAVR failure and demonstrates that survival depends on immediate surgical rescue and coordinated, sequential use of advanced mechanical circulatory support within an experienced multidisciplinary Heart Team.

Authors
Catarina Novo (1), Mariana Campos (1), Belisa Gomes (1), João Monteiro (1), João Cardoso (1), Nelson Santos (1), Paulo Neves (1)
Institutions
(1) Unidade Local de Saúde Gaia/Espinho, Vila Nova de Gaia, Porto

Adult Cardiac