The Cardiology team at Apollo Hospitals, Chennai yet again exhibited their expertise by handling a challenging elderly patient with critical aortic stenosis who suddenly developed in-hospital cardiac arrest. Emergency Transcatheter Aortic Valve Implantation (TAVI) was considered as the best treatment modality for such a high-risk patient.
A 67-years-old lady came to the Apollo Hospital Emergency Department at Chennai with heart failure. During her recent admission in another hospital, she was treated for similar symptoms and diagnosed to have critical calcific Aortic Stenosis (AS). Her echocardiogram revealed a trileaflet aortic valve with a valve area of 0.3 cm and a mean pressure gradient of 101mmHg with moderate left ventricular dysfunction with ejection fraction of 45%. Further she was diagnosed for hypertension, Rheumatoid Arthritis (RA) and operated for left femur fracture 5 years ago. She was stabilized with anti-failure measures and her pre-operative risk assessment Society of Thoracic Surgeons (STS) score was 7.71%, at the time of admission. She was evaluated by our cardiology team for transcatheter aortic valve replacement. Her epicardial coronaries were normal and her anatomy was suitable for transfemoral TAVI.
While waiting, patient suddenly developed in-hospital cardiac arrest and was resuscitated after 5 cycles of cardiopulmonary resuscitation. Post cardiac arrest her Glasgow Coma Score (GCS) was 5/15. Her neurological recovery post cardiac arrest was not clear as she was sedated, and on ventilator support. Neurologist opinion was sought and MRI brain showed no significant abnormality. Her revised STS score post arrest jumped to 38.34 making her inoperable. Considering her clinical status with high risk and indeterminate neurological status, it was difficult to decide on TAVI. Option of Balloon Aortic Valvuloplasty (BAV) was contemplated as bridge procedure until complete neurological recovery happened. As she was getting prepared for BAV as a bridge procedure, she was weaned off sedation and her neurological status was better and Glasgow coma scale (GCS) improved to 10/15.
Dr G. Sengottuvelu, Senior Consultant – Interventional Cardiology and his team at Apollo Hospitals, Chennai took the patient for emergency TAVI, despite high-risk status, and considered it as a life-saving procedure. She underwent TAVI using Evolut R (Medtronic) valve, which could be mobilized within a period of 6 hours. 26 mm Evolut R (Medtronic) valve was deployed through transfemoral approach after predilatation with 16mm Z-MED II (B. Braun interventional systems) balloon. Aortogram, transesophageal echocardiography (TEE) and hemodynamics were assessed post deployment which showed mild to moderate paravalvular leak. Post dilatation was done using Z-MED II 20 mm balloon during rapid ventricular pacing. Aortogram, TEE, hemodynamics was re-assessed, which showed trivial paravalvular leak and mean valvular gradient of 1.9mmHg. The patient was transferred to the coronary care unit with the temporary transvenous pacemaker, which was removed after two days.
Her post procedure hospital stay was very crucial. Although she was extubated 3 days later, her chest X-ray showed persistent bilateral infiltrates, which was initially considered as pulmonary edema. In spite of aggressive diuretic therapy, chest X-ray showed worsening infiltrates despite improved aortic valve hemodynamics and she was dependent on non-invasive ventilation. Pulmonologist and critical team decided to electively re-intubate her. Computed tomography of chest and bronchoscopy suggested alveolar hemorrhage possibly related to rheumatoid arthritis. She was put on steroids, showed significant improvement, and was extubated and discharged after 3 days. During her 4-month follow-up, patient clinically recovered well and her echocardiography reports showed significant signs of improvement.
Patients with critical aortic stenosis are at higher risk of cardiac arrest and are particularly difficult to resuscitate. TAVI is the only life-saving procedure that can be done with least risk in this high-risk situation. Challenges in performing emergency TAVI include cost, immediate availability of hardware, expert cardiology team and technical expertise in performing independent TAVI.
