CASE20220612_001

Salvaging hopeless patient with AS, chronic refractory heart failure, liver and kidney failure, and prolonged resuscitation during TAVI

By Teguh Santoso, Linda Lison
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Presenter

Teguh Santoso

Authors

Teguh Santoso1, Linda Lison1

Affiliation

Medistra Hospital, Indonesia1
Valve - Aortic Valve

Salvaging hopeless patient with AS, chronic refractory heart failure, liver and kidney failure, and prolonged resuscitation during TAVI

Teguh Santoso1, Linda Lison1

Medistra Hospital, Indonesia1

Clinical Information

Patient initials or Identifier Number

MN

Relevant Clinical History and Physical Exam

Male, 72 year old.May –July 2021: 3 months hospitalizations due to refractory congestive heart failure.Lab: ureum 92 mg/dL, creatinine 1.5 mg/dL, eGFR 45.9 cc/m/1.73m2 (Stage 3a), glucose209 mg/dL, HbA1C 8.2, Bilirubin - Direct:3,53 mg/dL/Indirect: 1,93 mg/dL, SGOT 113 U/L, SGPT 358 U/dL, NT ProBNP 18392 pg/mL (N: < 125 pg/mL)ECG: SR, poor r waves V1-V3, ST/T changes in I, aVL, V3-V5Chest film: fluctuating pulmonary edema.

Relevant Test Results Prior to Catheterization

Severe, calcified AS, AVA 0.7 mm2, Max PG 72 mmHg, Mean PG 36 mmHg, VTI 91.4 cm/s, moderate AR, LV dilatation, EF 36%, moderate MR, MAC. EuroScore II 43.93%, STS risk for mortality 9.3%, risk of morbidity or mortality 41.6 %

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Relevant Catheterization Findings

Normal coronaries.

Interventional Management

Procedural Step

During deployment VF ensued, CPR was performed. Device redeployed but appeared constrained with a narrow transverse diameter and string sign indicating infolding of struts. Rigorous CPR performed. Finally after more than 62 minutes, heart responded to pacing. Hemodynamics became acceptable, pressure gradient 8 mmHg. No pulmonary edema. AR index 21. After TAVI patient had prolonged acute confusional state (for around 3 weeks) without other neurological sequels. Brain CT showed only age-related atrophy. However, 2.5 months later he began to show signs and symptoms of heart failure again. Echocardiogram showed max PG 35 mmHg, mean PG 20 mmHg. TEE demonstrated infolded valve, systolic flow convergence and AR. Decided to treat it. Rotational fluoroscopy showing the maldeployed valve.  PPG across AoV 14 mmHg. Moderate AR. AR index 21.  To avoid crossing the struts, the valve was crossed using a pigtail catheter & a 0.35¡± J-tip Terumo wire by prolapsing the wire across the valve. Balloon aortic valvuloplasty was done; resulting in mild AR, but with ¡°normal¡± AR index (33). PPG 8 mmHg. TTE showed better expanded THV almost without infolding and no hemodynamic gradient across the valve. There was no annular hematoma or pericardial effusion post-procedure on echo. Liver and kidney function returned to normal as the derangement was ¡°functional¡±. Patient was subsequently well, no symptom, could resume normal daily activities, NYHA 1, practically without neurological sequels. 
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Case Summary

A HOPE-less patient with AS, chronic refractory heart failure, liver and kidney failure, and prolonged resuscitation during TAVI is presented. After TAVI all the above medical problems gradually weaned off. He also had infolded valve which was treated with BAV with acceptable result. Never lose HOPE, because HOPE sees the invisible, feels the intangible, and achieves the impossible (Hellen Keller).