Postoperative paraplegia after transapical transcatheter aortic valve implantation

Abstract

An 84-year-old man with severe aortic valve stenosis underwent transcatheter aortic valve implantation (TAVI). We selected a transapical approach TAVI because he had a 48-mm abdominal aortic aneurysm and his descending aorta was covered with severe atherosclerosis, a so-called "shaggy aorta". A 26-mm Sapien XT prosthesis (Edwards Lifesciences, Irvine, CA, USA) was successfully implanted, and TAVI was performed using cardiopulmonary bypass. His postoperative clinical course was unremarkable on the first day. On postoperative day 3, however, his systemic circulation suddenly collapsed due to cardiac tamponade. We performed an emergency re-thoracotomy. This operation improved his systemic circulation, but he had no movement in either leg. Magnetic resonance imaging showed spinal cord ischemia around the T10 level and acute multifocal micro cerebral infarctions. The cause of his neurological symptoms was thought to be spinal cord ischemia brought about by the shaggy aorta and low blood pressure due to cardiac tamponade after TAVI. <Learning objective: Postoperative spinal cord injury is caused by hypotension embolisms, and aortic dissection particularly in patients with severe aortic arteriosclerosis. Spinal cord ischemia is a rare complication after transcatheter aortic valve implantation because the descending aorta is not operated upon. However, it is necessary to keep in mind that postoperative hemodynamic instability can cause spinal cord ischemia in patients with a shaggy aorta.>

The Shaggy Aorta Syndrome: An Updated Review

“…26 A filtration-type embolus protection device with a nitinol basket and polyester fabric could be introduced through a 12F sheath and opened in the supraceliac aorta during the stentgraft procedure, as described by Sanada et al 11 Although some studies suggest that endovascular approach is contraindicated for SA due to risk of embolization, EVAR, it may be considered as an option for aneurysm complications, like in aortoenteric fistula, as reported by Hori et al 15 An effective and less invasive treatment for aortic stenosis in surgical high-and medium-risk patients is TAVI. Stroke and paraplegia 55 are potential complications associated with TAVI, and SA increases the risk for cerebral complication. In this context, Nomura et al 56 and Sawazaki et al 36 adopted a modified artery isolation technique without using conventional protection devices through bilateral axillary artery perfusion resulting effective for the prevention of cerebral embolism.…”

Cutaneous-Pericardial Fistula: Rare Complication of Transapical Aortic Valve Replacement—Case Report and Literature Review

“…Despite this, minithoracotomies are often associated with chronic pain and surgical site infection (SSI) [6,7]. TA approach in TAVR proved itself a feasible solution, but with a group of rare and poorly studied complications [8][9][10].…”

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“…(520) En el TEVAR, la SA fue identificada como un factor de riesgo independiente de isquemia de médula espinal, (521) embolia mesentérica (522), embolización cerebral en EVAR (523,524) (aun a pesar de la oclusión de la arteria subclavia izquierda) (525), aumento de la embolización renal y mesentérica en EVAR y endoprótesis fenestradas (526,527); por otra parte, está demostrado el aumento en ACV y paraplejía en los pacientes que se realizan TAVI. (528) Dado todo lo expuesto previamente se debe prestar especial atención a este hallazgo en las imágenes, porque aumenta el riesgo de embolización en el tratamiento (endovascular o quirúrgico) de la patología aórtica (aneurismas, pseudoaneurisma o síndromes aórticos).…”

“…(567,568) Lo ideal es que los pacientes entren en remisión clínica antes de someterse a reparación electiva de un aneurisma secundario a un cuadro de aortitis. (526)(527)(528)(529)(530)(531)(532) Manejo quirúrgico-endovascular El manejo de pacientes con arteritis de Takayasu usualmente incluye esteroides durante la fase activa y el tratamiento de la hipertensión durante la fase fibrótica. No obstante, las complicaciones en la fase crónica usualmente se deben a estenosis y a aneurismas de la aorta y los grandes vasos.…”