Prosthesis-to-Prosthesis Balloon Interaction During TAVR Causing Aorto-Mitral Curtain Injury and Left Ventricular Pseudoaneurysm

Figures

• 

  Figure 1. Preprocedural Transthoracic Echocardiography Demonstrating Severe Aortic Stenosis Preprocedural transthoracic echocardiography demonstrated severe aortic stenosis with a peak aortic velocity of 4.03 m/s, peak transvalvular gradient of 64.9 mm Hg, and mean transvalvular gradient of 45 mm Hg.

• 

  Figure 2. Preprocedural Computed Tomography Measurements for TAVR Planning Computed tomography reconstruction used for procedural planning demonstrating annular and left ventricular outflow tract (LVOT) measurements. Annular area measured 348.9 mm2 with a perimeter of 67.5 mm, and LVOT area measured 284.2 mm2 with a perimeter of 60.9 mm.

• 

  Figure 3. Balloon Expansion During Transcatheter Aortic Valve Replacement Fluoroscopic image obtained during deployment of a 26-mm Edwards SAPIEN 3 Ultra RESILIA valve, demonstrating close proximity between the transcatheter heart valve system and the surgical bioprosthetic mitral valve.

• 

  Figure 4. Bioprosthetic Mitral Valve Protrusion Into the Left Ventricular Outflow Tract Preprocedural transthoracic echocardiography demonstrating anterior protrusion of the surgical bioprosthetic mitral valve into the left ventricular outflow tract (arrow), resulting in left ventricular outflow tract narrowing.

• 

  Figure 5. Preprocedural Computed Tomography Demonstrating Constrained Mitro-Aortic Anatomy Preprocedural cardiac computed tomography demonstrates close spatial proximity between the surgical bioprosthetic mitral valve, left ventricular outflow tract, and aortic annular complex, resulting in markedly constrained mitro-aortic anatomy.

• 

  Figure 6. Retrospectively Identified Angiographic Evidence of Aorto-Mitral Curtain Injury Retrospective review of the completion aortogram demonstrated mild paravalvular regurgitation and focal contrast extravasation adjacent to the aorto-mitral continuity (arrow), representing the earliest angiographic evidence of injury that was not recognized during the index procedure.

• 

  Figure 7. Contrast-Enhanced Computed Tomography Demonstrating a Pseudoaneurysm Neck Adjacent to the Aorto-Mitral Curtain (A) Axial contrast-enhanced computed tomography demonstrating the pseudoaneurysm neck (arrow) and the contained pseudoaneurysm cavity (∗). (B) Coronal reconstruction demonstrating contrast extravasation through the pseudoaneurysm neck (arrow).

• 

  Figure 8. Echocardiographic Demonstration of Aorto-Mitral Curtain Perforation Following readmission, transthoracic echocardiography demonstrated color Doppler flow across the aorto-mitral curtain perforation (arrow) without evidence of pericardial effusion or cardiac tamponade.

• 

  Visual Summary. Prosthesis-to-Prosthesis Interaction During Transcatheter Aortic Valve Replacement and Subsequent Clinical Course CT = computed tomography; TEE = transesophageal echocardiography; TAVR = transcatheter aortic valve replacement.