Evaluation of Shock Following TAVR
A 78-year-old female patient with prior medical history of hypertension, hyperlipidemia, and rheumatoid arthritis was admitted to the hospital with acute pulmonary edema and other signs and symptoms of congestive heart failure. A two-dimensional echocardiogram and left heart catheterization revealed low flow, low gradient severe aortic stenosis with a calculated valve area of 0.6 cm2 and preserved ejection fraction. Cardiac catheterization showed no evidence of coronary artery disease (CAD) (Figures 1-3). The patient underwent successful transcatheter aortic valve replacement (TAVR) via femoral approach using a balloon-expandable 26 mm Edwards SAPIEN 3 valve (Edwards Lifesciences, Inc., Irvine, CA) (Figure 4). The patient was in complete heart block post procedure and received a temporary pacer wire. A post-procedure echocardiogram showed a well-seated normally functioning prosthetic valve and normal ventricular function. Sixteen hours post-procedure, the patient developed epigastric discomfort accompanied by hypotension. An electrocardiogram was performed, which showed no evidence of acute ST-segment elevation myocardial infarction. A repeat bedside echocardiogram revealed an ejection fraction of 20% with akinesis in the apical, anterior, and anteroseptal wall segments (Video 1).
Figure 1: Coronary Angiography Prior to TAVR Showing no Underlying CAD
Figure 2: Coronary Angiography Prior to TAVR Showing no Underlying CAD
Figure 3: Coronary Angiography Prior to TAVR Showing no Underlying CAD
Figure 4: Aortogram Showing Successful Placement of a Balloon-Expandable Valve
Video 1: Presence of Wall Motion Abnormality in the Basal to Mid-Antero-Septal Segments on Echocardiogram in Parasternal Long-Axis View
What of the following should be considered in the differential diagnoses for development of acute hypotension following TAVR?