Zone 0 TEVAR With Dissection Endovascular Stent For Management Of Embolized Aortic Valve During TAVR
Thekla Bacharach, MD1, James Z. Keeton2, Anand Prasad2, Ahmed Almomani, MD2, Anand Dayama, MD1.
1Sanford USD Medical Center, Sioux Falls, SD, USA, 2UT San Antonio, San Antonio, TX, USA.
DEMOGRAPHICS:A 64-year-old female presented with severe dyspnea due to restenosis of a bioprosthetic aortic valve (2013), effective aortic orifice size was 0.89 cm2. Her past medical history was significant for DM type II, HTN, CHF (NYHA class III), and morbid obesity (114kg). She was a high-risk transcatheter aortic valve replacement (TAVR) candidate.HISTORY:During TAVR, the CoreValve was successfully deployed with rapid ventricular pacing. However, it was under-expanded. While positioning the balloon for post dilatation, the valve embolized into the aorta arch. The CoreValve was unstable and spinning in the aortic arch (Image 1.1). She was not a candidate for open explant due to comorbidities and prior surgical history.PLAN:The embolized valve was snared using a Gooseneck snare while maintaining wire access through the aortic valve. A second valve was then deployed completing the valve-in-valve TAVR. To address the embolized valve, the snared CoreValve was positioned and stabilized with forward traction in the aortic arch proximal to the innominate artery. The bare metal dissection endovascular stent was deployed in Zone 0, securing the valve in the ascending aorta (Image 1.2). The final aortogram demonstrated normal flow in the coronary arteries and aortic arch branch vessels without evidence of extravasation or dissection. The patient was neurologically intact. She was discharged on POD#3DISCUSSION:A valve embolization during transcatheter aortic valve replacement is a rare but catastrophic complication. Endovascular management with the bare metal dissection stent in Zone 0 for embolized aortic valve during TAVR is feasible. It is an excellent alternative to open explant in high-risk patients. The bare dissection stent secures the valve in the aorta while allowing perfusion to the supra-aortic trunks. 
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