Let it Bleed! 

Madam Law, a 78-years-old lady, had history of hyperlipidemia and atrial fibrillation. She was referred from family physician for recent onset of decrease exercise tolerance and heart murmur on physical examination. 

Echocardiogram confirmed severe degenerative aortic stenosis with aortic valve area of 0.7cm² and mean gradient of 46mmHg. Left ventricular ejection fraction was preserved. Coronary angiogram did not find any significant coronary artery disease. The case was discussed in Heart team and her STS score for Surgical AVR was 5.4%, Logistic euroscore was 12.7% while frailty score was 5. She was deemed a reasonable candidate for TAVI and pre-operative CT aortogram was performed. It showed an aortic annulus perimeter of 68mm which fit with a 26mm Medtronic Evolut R TAVI device. The left coronary origin was low with a coronary height of 8mm. Peripheral vasculature was free from significant disease and was suitable for transfemoral approach for TAVI. 

TAVI procedure was performed in cardiac catheterization laboratory under Monitor Anesthesia Care (MAC). Claret cerebral protection device was inserted via right radial artery for stroke prevention during TAVI procedure. Coronary protection with a coronary wire via a JL4 guiding was performed from left radial artery. Right femoral arterial access was obtained for TAVI device insertion. Aortic valve was crossed with standard technique and a pre-formed curve stiff guidewire was parked inside LV cavity. (Figure 1) Direct Implantation of a 26mm Evolut R device was performed. (Figure 2) Device was successfully implanted to the target depth with one attempt. However shortly after the implantation, blood pressure of the patient began to drop. A quick aortogram did not found significant aortic regurgitation or coronary flow impairment. Patient shortly developed pulseless electric activity which required CPR. She was intubated by anesthetist and a quick transthoracic echocardiogram showed massive pericardial effusion with cardiac tamponade. (Figure 3) Immediate pericardiocentesis was performed with fresh blood aspirated. (Figure 4) Blood pressure began to regain after partial relief of tamponade. Fluid and blood product were given. However, there was continuous drainage from the pigtail despite more than 1L of blood aspirated and blood pressure began to drop again. Massive fluid and blood product were given and autotransfusion of aspirated blood was given back to the patient via the central line. Left ventriculogram was performed and confirmed there was LV perforation by the stiff guidewire. (Figure 5) 

CTS was urgently consulted for surgical repair while VA ecmo was inserted at the same time to support the circulation. The circuit was set up with reasonable flow at the beginning but started to drop while there was continuous drainage of the pigtail. We then encountered the dilemma of maintaining intrinsic cardiac output by relieving the tamponade but at the same time significant leakage from the LV while there is good intrinsic cardiac contraction. We decided to clamp the drain so that cardiac tamponade resulted (Figure 6) and prevent further blood loss from the circuit while systemic circulation was able to be maintained via the VA ECMO. Mean arterial pressure was able to be maintained at around 60mmhg after this maneuver and the patient was sent to the OT for surgical repair of the LV tear. A 1.5cm LV apical tear was found and was sutured. After the repair, the hemodynamic of the patient become stabilized with fair intrinsic cardiac output. 

She gradually stabilized and wean off ECMO 2 days later. After a prolong course of treatment and intensive rehabilitation, she was discharged home 2 months later. Follow up echocardiogram showed satisfactory LV ejection fraction and aortic prosthetic function. She remained free of cardiac symptom and was independent in activities of daily living.