Protamine-Exacerbated Right Ventricular Failure After TAVR in Critical Aortic Stenosis

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  Visual Summary. Timeline of Protamine-Induced RV Failure After TAVR AVA = aortic valve area; CAD = coronary artery disease; CTO = chronic total occlusion; CVP = central venous pressure; DI = dimensionless index; EF = ejection fraction; FAC = fractional area change; IABP = intra-aortic balloon pump; RCA = right coronary artery; RV = right ventricular; TAPSE = tricuspid annular plane systolic excursion; TAVR = transcatheter aortic valve replacement; TEE = transesophageal echocardiography.

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  Figure 1. Transthoracic Echocardiography on Presentation Showing Aortic Stenosis (Left) Aortic-focused zoomed-in parasternal long-axis view demonstrating severely reduced aortic valve cusp separation (0.25 cm). (Right) Continuous-wave Doppler in the apical 4-chamber view demonstrating aortic valve area of 0.49 cm2, suggesting critical aortic stenosis, with a mean gradient of 32 mm Hg, and maximum velocity of 3.51 m/s.

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  Figure 2. Right Ventricular Dysfunction at Baseline (A) RV-focused apical 4-chamber view on TTE demonstrating dilated right ventricle, with a mid-RV short-axis width of 4.42 cm and basal RV short-axis width of 4.74 cm. (B) RV-focused apical 4-chamber view on TTE demonstrating fractional area change of 21.4%, consistent with dilated RV. (C) TAPSE in M-mode is reduced at 1.04 cm, consistent with reduced RV systolic function. (D) Pulse-wave Doppler of the RV septum on TTE demonstrating reduced RV S′ of 6.31 cm/s, consistent with reduced RV systolic function. RV = right ventricular; TAPSE = tricuspid annular plane systolic excursion; TTE = transthoracic echocardiography.

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  Figure 3. Fluoroscopy Demonstrating Deployment of the 26-mm Sapien 3 Ultra Resilia Bioprosthetic Valve Under Rapid Pacing

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  Figure 4. X-Plane of Midesophageal 4-Chamber on Transesophageal Echocardiography Demonstrating an Underfilled Left Ventricle and Overloaded Right Ventricle

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  Figure 5. Fluoroscopy Demonstrating Appropriate Placement of Impella RP in the Vicinity of the Left Upper Pulmonary Artery and Appropriate Placement of the Intra-Aortic Balloon Pump in the Thoracic Descending Aorta The temporary right ventricular pacing wire and the recently deployed 26-mm Sapien 3 Ultra Resilia bioprosthetic valve is also visualized.