Type A aortic dissection following transcatheter aortic valve implantation

Padilla-Serrano, Antonio; Ruiz Gómez, María Lara; Cárdenas Cruz, Antonio

doi:10.1016/j.medcle.2024.05.019

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B) 3D reconstruction of computed tomography angiography of the thoracic aorta showing a type A aortic dissection in which the entry port is partially obstructed by the stent of the aortic prosthesis. FL, false lumen; TL, true lumen; AoP, aortic prosthesis." ] ] ] "textoCompleto" => "Transcatheter aortic valve implantation (TAVI) has provided an alternative treatment option for a group of patients with aortic stenosis for whom surgery was not indicated due to high risk. Complications associated with TAVI involving the aorta are rare, with aortic dissection accounting for only 0.2% of such complications.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> This is a potentially catastrophic complication and represents unique management challenges in this population.We report the case of an 82-year-old man with severe aortic stenosis who was proposed for transfemoral TAVI with the 34mm Medtronic Evolut™ PRO+ self-expanding prosthesis. The procedure was complex with several attempts to place the prosthesis due to displacement of the device within the aorta prior to final implantation. Post-implantation control aortography (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A) and thoracic computed tomography angiography (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B) show aortic dissection from the non-coronary sinus, affecting the ascending aorta, aortic arch and descending aorta. A conservative strategy of strict blood pressure control with beta-blockers was chosen. In addition, close follow-up with serial chest CT angiography showed no distal enlargement of the aortic dissection and poor organ perfusion. At 4-month follow-up, chest CT angiography showed a progressive increase in thrombosis of the false lumen in the most distal region.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Due to high early mortality, treatment of these lesions often requires open surgical repair; however, TAVI patients are often at high surgical risk prior to complications. For patients with poor organ perfusion despite medical treatment, endovascular repair of the ascending aorta is a therapeutic option.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> The body of the prosthesis itself can also serve as a definitive treatment if it successfully occludes the entry point of the dissection.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> For iatrogenic retrograde aortic dissections, it seems safe to maintain a conservative approach under strict imaging monitoring.All patients with dissection should have their heart rate and blood pressure closely monitored with intravenous beta-blockers. If beta-blockers are contraindicated, a dihydropyridine calcium channel blocker or sodium nitroprusside may be used.To date, there are no studies in the literature specifically reporting on outcomes after aortic dissection during TAVI; however, results from several studies in high-risk patients and those with iatrogenic dissection can be generalised. The study by Mehta et al. reported an in-hospital mortality of 52.5% in patients older than 70 years with medically treated type A aortic dissection, 45.5% in those older than 80 years, and 62.5% in those older than 85 years.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> Although iatrogenic aortic dissection is associated with higher mortality than spontaneous dissection, prompt diagnosis and treatment during TAVI can help stabilise the dissection and minimise complications from poor perfusion or cardiac tamponade.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>As our case shows, and with the limitations of not having studies with a high level of scientific evidence, medical treatment is not a wasteful or palliative measure and suggests that it may be a reasonable therapeutic option in the population complicated by type A aortic dissection during TAVI.Ethical responsibilitiesInstructions to authors and ethical responsibilities have been taken into account. In addition, the hospital’s protocols and procedures related to the publication of patient data as well as the privacy of the subject have been followed.FundingThe authors declare that they have not received any financial support.AuthorshipAll authors have contributed equally to the conception, drafting and final approval of the letter to the editor." "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Ethical responsibilities" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Authorship" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1307 "Ancho" => 2667 "Tamanyo" => 185995 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "A) Aortography showing dissection of the ascending aorta. B) 3D reconstruction of computed tomography angiography of the thoracic aorta showing a type A aortic dissection in which the entry port is partially obstructed by the stent of the aortic prosthesis. FL, false lumen; TL, true lumen; AoP, aortic prosthesis." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Perioperative results and complications in 15,964 transcatheter aortic valve replacements: prospective data from the GARY registry" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "T. Walther" 1 => "C.W. Hamm" 2 => "G. Schuler" 3 => "A. Berkowitsch" 4 => "J. Kötting" 5 => "N. Mangner" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2015.03.034" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2015" "volumen" => "65" "paginaInicial" => "2173" "paginaFinal" => "2180" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25787198" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Injuries to the aorta, aortic annulus, and left ventricle during transcatheter aortic valve replacement: management and outcomes" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N.B. Langer" 1 => "N.B. Hamid" 2 => "T.M. Nazif" 3 => "O.K. Khalique" 4 => "T.P. Vahl" 5 => "J. White" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCINTERVENTIONS.116.004735" "Revista" => array:5 [ "tituloSerie" => "Circ Cardiovasc Interv" "fecha" => "2017" "volumen" => "10" "paginaInicial" => "e004735" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28039322" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Iatrogenic dissection of the ascending aorta during TAVI sealed with the CoreValve revalving prosthesis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S.H. Ong" 1 => "R. Mueller" 2 => "U. Gerckens" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/ccd.22900" "Revista" => array:6 [ "tituloSerie" => "Catheter Cardiovasc Interv" "fecha" => "2011" "volumen" => "77" "paginaInicial" => "910" "paginaFinal" => "914" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21425427" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute type A aortic dissection in the elderly: clinical characteristics, management, and outcomes in the current era" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R.H. Mehta" 1 => "P.T. O’Gara" 2 => "E. Bossone" 3 => "C.A. Nienaber" 4 => "T. Myrmel" 5 => "J.V. Cooper" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0735-1097(02)02005-3" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2002" "volumen" => "40" "paginaInicial" => "685" "paginaFinal" => "692" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12204498" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of type A aortic dissections: a meta-analysis of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F.H.W. Jonker" 1 => "F.J.V. Schlosser" 2 => "J.E. Indes" 3 => "B.E. Sumpio" 4 => "D.M. Botta" 5 => "F.L. Moll" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.athoracsur.2009.11.020" "Revista" => array:6 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "2010" "volumen" => "89" "paginaInicial" => "2061" "paginaFinal" => "2066" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20494094" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/unassign/S238702062400487X/v1_202411010428/en/main.assets" "Apartado" => null "PDF" => "https://static.elsevier.es/multimedia/23870206/unassign/S238702062400487X/v1_202411010428/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S238702062400487X?idApp=UINPBA00004N"]

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