Hemodynamic Assessment of Cardiogenic Shock During TAVR

A 76-year-old female patient with a prior history of coronary artery bypass surgery, chronic kidney disease, and chronic obstructive lung disease presented with exertional shortness of breath on minimal activity such as going up a flight of stairs. Coronary and graft angiography revealed patent right and left circumflex coronary arteries and grafts (left internal mammary graft to the left anterior descending artery and a saphenous vein graft to a diagonal artery). Transthoracic echocardiography showed severe aortic stenosis and preserved left ventricular (LV) systolic function. She was considered high risk for surgical aortic valve replacement, and it was elected to replace her aortic valve using a transcatheter approach. Cardiac computed tomography evaluation of the aortic annulus indicated that a 26 mm CoreValve Evolut R (Medtronic, Inc.; Minneapolis, MN) self-expanding transcatheter heart valve would be appropriate with 16% oversizing. Transcatheter aortic valve replacement (TAVR) using a 26 mm CoreValve Evolut R (Medtronic, Inc.; Minneapolis, MN) valve was performed from the right femoral approach under conscious sedation. Immediately following valve deployment, the patient was noted to be hypotensive. Left ventricular-aortic simultaneous pressure tracings are shown at baseline, following valve deployment and after a subsequent percutaneous intervention (Figure 1). Ascending aortic angiography is also shown immediately following valve deployment (Video 1).

Figure 1

Figure 1

Video 1

What was the cause of the patient's hemodynamic decompensation, and what acute intervention was performed?

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