Contained Aortic Root Rupture: A Rare Complication after Transfemoral Implantation of Self-Expandable Aortic Valve Bioprosthesis

Introduction: Since the first TAVI in 2002 great technical progress as well as clinical experience have been made, resulting in reduced rates of periprocedural complications. Only rare cases of aortic root aneurysms after balloon-expandable TAVI have been described.

Case Report: An 82-year-old male patient was referred to our institution with acute heart failure. After exclusion of acute coronary syndrome, revealing a single-vessel CAD, echocardiography showed combined aortic valve disease with severe stenosis. In his past medical history the patient has been diagnosed with type II diabetes, hypertension, chronic renal failure and symptomatic carotid artery stenosis. Besides porcelain aorta CT-Scan (MSCT) revealed an aortic anulus diameter of 25.5 mm with appropriate distance to both coronary ostia and regular characteristics of the aortic root. With an EURO-Score of 24.03 transfemoral TAVI was performed. Due to severe calcifications of the aortic anulus and LVOT a self-expandable bioprosthesis (Symetis Acurate TF Neo Size L) was implanted in optimal positioning. The postprocedural course went ordinary and the patient was discharged with a transvalvular gradient of 12/6 mm Hg and only mild paravalvular leakage, fully recovered 7 days after the procedure. After three months the patient was re-admitted to our institution with recurrent heart failure. Echocardiography showed moderate to severe paravalvular leakage and dilatation of the right coronary cusp (RCC). Invasive angiography of the aortic root showed a contained aortic root rupture in close proximity to upper crown of the previously implanted bioprosthesis and could be confirmed by MSCT. Due to the patient's impaired general condition and a clearly increased perioperative risk, surgical on-pump replacement of the aortic root was dismissed. After prolonged medicamentous recompensation, the patient developed cardiogenic shock as a consequence of complete aortic root rupture. Due to the infaust prognosis cardiopulmonary resuscitation was not performed.

Conclusion: This is one of the first reports about late aortic root rupture after TAVI with a self-expandable bioprosthesis. As few similar reports have been published using balloon-expandable valves this late but potentially fatal complication seems to be independent of the implantation mechanism. Consequently contained aortic root rupture should generally be taken into consideration evaluating clinical deterioration or unexpected death after TAV.