Complication Mitigation Flashcards
RV Perforation
a. Will present as late hypotension (slow leak)
b. Check echo to check wire position in RV
i. Check for pericardial effusion in subcostal 4-chamber view (TTE)
c. Remove temp pacing wire and discard to avoid interaction with perforated site
i. Move TVP to a different access site
d. Pericardiocentesis to drain fluid from pericardium vs. pericardial window
Failure of Evolut DCS to track in peripheral anatomy
a. Pay attention to Anterior Ca++»_space; can suggest to stick higher in vessel
b. DO NOT force or push harder on DCS
c. Review anatomical considerations
d. Use a small amount of traction on the wire to help the device track
e. Rotate DCS ¼ turn counter/clockwise and push to advance
f. Pre-dilate vessel using dilators
g. Propofol trick (rub some propofol on the sheath to assist with lubricity)
h. External sheath
i. Buddy wire in the reference pigtail catheter to create a rail
j. Exchange for stiffer working wire (ie. Lunderquist)
k. Convert to alternative access
Failure of Evolut DCS to track in and around aortic arch
Due to tortuosity, horizontal aortic root, enlarged aortic root, bicuspid anatomy, failed TAV or SAV
a. DO NOT force or push harder on DCS
b. Review anatomical considerations
c. Use a small amount of traction on the wire to help the device track around the arch
d. Pull DCS into descending aorta and rotate DCS no more than ¼ turn (2 o’clock position) and re-advance (moves single spine to a different orientation)
e. Buddy wire in the reference pigtail catheter to create a rail and open up arch
f. Exchange for stiffer working wire (ie. Lunderquist)
g. Consider long external sheath
h. Use peripheral balloon to deflect DCS away from obstruction (not always successful)
i. Snare technique
j. Convert to alternative access
Heart block
Conduction disturbance due to crossing the valve (insertion of wire, catheter, or DCS), during a BAV, or with deployment of Evolut
a. Pre-release:
i. Turn temp pacing ON
ii. Full or partial recapture and position higher
b. Post-release:
i. Keep temp pacing ON
ii. Consider moving TF temp pacer to internal jugular (IJ) access so that patient may ambulate post-procedure
iii. Monitor patient telemetry for 24 hours
iv. Consider EP consult
LV Perforation
crossing aortic valve with straight wire, following heparin administration, annular contact to 80%
a. Recognize signs of pericardial effusion
i. Hypotension
ii. Narrow pulse pressure (difference in systolic vs diastolic is small)
iii. Tachycardia
iv. Pulsus paradoxus (BP drop with inspiration)
b. Check echo to check wire position in LV
i. Check for pericardial effusion in subcostal 4-chamber view (TTE)
c. Pericardiocentesis to drain fluid from pericardium vs. pericardial window (open heart)
Mitral valve interaction with the wire
Hypotension upon wire placement in LV due to MR
a. Check fluoro to look at position of wire and obvious mitral interaction/entanglement
b. Check EKG to rule out rhythm issue (ex. bradycardia due to heart block)
c. Check echo to check wire position in apex
i. Rule out pericardial effusion (would also have tachycardia if LV perforation)
ii. Diagnose MR
d. Reposition wire using pigtail catheter
Aortic Insufficiency (AI) leading to Hemodynamic Compromise (after Pre-BAV)
Hypotension after pre-BAV due to open AI
a. Stabilize patient
b. Check EKG to rule out rhythm issue (ex. bradycardia due to heart block) or ST segment changes
c. Perform angio to check AI or contrast extravasation (consider annular dissection/rupture)
d. Check echo
i. Assess AI
ii. Check LV function
iii. Look for anatomical changes (ie. annular rupture, pericardial effusion, etc.)
e. Deploy valve quickly to 80% to reduce AI
i. Use pacing upon deployment to stabilize
ii. Avoid taking multiple root shots (will worsen AI)
iii. Patient may not tolerate multiple recaptures
iv. Consider bypass for hemodynamic support if patient is unstable
Parallax in the Cusp Overlap view
a. Try Near Cusp Overlap view
b. Reposition wire to ensure placement in non-right commissure
c. Stiffer working wire (ex. Lunderquist)
Infolding of the TAV
Can be induced during the loading process or upon deployment/recapture in the presence of dense focal Ca++
a. Prior to full release (at 80% deployed)
i. Presents as unusual appearance of device with AI
ii. Check fluoro in LAO view to confirm infold if unable to evaluate in Cusp Overlap
iii. Check echo to visualize infold in short axis view (will see a PacMan or bean shape)
iv. Recapture and remove system; prep new valve and system for implant
v. Consider pre-BAV to minimize infold risk (especially on 34mm)
vi. Consider targeting slightly lower depth to allow for more frame expansion
b. After full deployment – frame remains under expanded
i. Presents as unusual appearance of device with AI and if severe, hypotension
ii. Check fluoro in LAO view to confirm infold if unable to evaluate in Cusp Overlap
iii. Check echo to visualize infold in short axis view (will see a PacMan or bean shape)
iv. Be careful removing DCS after full deployment»_space; valve could embolize with nose cone interaction
v. Post-BAV to alleviate infold
1. Be careful when advancing balloon so that it does not get stuck
2. Rapid pace to ensure valve stability
3. If cannot advance balloon, may need to snare TAV and pull aortic then implant new valve
Coronary obstruction during Deployment
a. Prior to full release (at 80% deployed)
i. Check EKG for ST segment changes
ii. Check coronary flow or PVL via angiography
iii. Check echo to rule out AI/MR, look at LV function
iv. Once coronary occlusion is confirmed:
1. Recapture valve and remove system
2. Stabilize patient
3. Coronary protection prior to proceeding with new valve implantation (“snorkeling”)
b. Upon full deployment of properly implanted valve
i. Check EKG for ST segment changes
ii. Check coronary flow or PVL via angiography
iii. Check echo to rule out AI/MR, look at LV function
iv. Once coronary occlusion is confirmed:
1. Stabilize patient
2. Prepare for coronary intervention (PCI)
3. In extreme cases, may need to prepare to snare deployed valve into ascending AO
Failure of Paddle to Release from Pocket
Paddle hang up after full deployment
a. DO NOT PULL on DCS as valve will embolize
b. Ensure that capsule is opened all the way
c. Check another fluoro view to confirm that paddle is still attached
d. Push on DCS
e. Push/pull wire to change pressure on catheter and help release
f. Push and rotate DCS ¼ turn to see if slight torque will help release
g. Slowly recapture to push paddle off spindle»_space; turn deployment knob in opposite direction to advance capsule
Coronary obstruction (with pop out)
Valve moves aortic on release and is 5-10mm above annulus
a. Evaluate patient stability
i. Check EKG for rhythm changes or ST segment changes
ii. Check BP»_space; may have hypotension
iii. Check coronaries and PVL via angiography
iv. Check echo to rule out AI/MR, look at LV function
b. Stable patient: BP stable but ST segment changes, reduced flow in coronaries on angio, reduced LV function
i. Snare TAV into ascending aorta below innominate artery
1. Remove reference pigtail and use contralateral arterial access for snare
2. Consider L radial access for secondary snare, if needed
ii. Maintain position with snare until new valve is implanted
1. Release secondary snare or may need radial access for reference pigtail for new valve implantation
iii. Can also test coronary flow by inflating balloon sized to waist of TAV and injecting contrast in AO
c. Unstable patient: BP unstable, ST segment changes, possible arrhythmias, absent flow in coronaries on angio, reduced LV function
i. Stabilize patient
ii. Snare TAV into ascending aorta below innominate artery
1. Remove reference pigtail and use contralateral arterial access for snare
2. Consider using a balloon sized to bigger than waist of TAV to pull valve into ascending aorta
iii. Perform chest compressions if needed
iv. Consider going on pump
v. Once stable, maintain position with snare until new valve is implanted
1. May need radial access for reference pigtail for new valve implantation
Device embolization (Aortic)
Valve moves aortic upon release, may result in TAV floating freely
a. Verbalize importance of maintaining LV wire position
b. Evaluate patient stability
i. Check EKG for rhythm changes or ST segment changes
ii. Check BP»_space; may have hypotension
iii. Check coronaries and PVL via angiography
iv. Check echo to rule out AI/MR, look at LV function
c. Stable patient:
i. Evaluate if TAV can remain in place vs. snare + implant new valve
1. Consider STJ height, SOV diameter, coronary heights, aortic apposition (know Asc AO measurement vs. outflow)
2. Do not want to create tube graft and prevent coronary flow
ii. Snare TAV into ascending aorta below innominate artery
1. Remove reference pigtail and use contralateral arterial access for snare
2. Consider L radial access for secondary snare, if needed
iii. Maintain position with snare until new valve is implanted
1. Release secondary snare or may need radial access for reference pigtail for new valve implantation
d. Unstable patient:
i. Stabilize patient
ii. Snare TAV into ascending aorta below innominate artery
1. Remove reference pigtail and use contralateral arterial access for snare
2. Consider using a balloon sized to bigger than waist of TAV to pull valve into ascending aorta
iii. Perform chest compressions if needed
iv. Consider going on pump
v. Once stable, maintain position with snare until new valve is implanted
1. May need radial access for reference pigtail for new valve implantation
Device embolization (Ventricular)
Valve dives into LV upon release
a. Evaluate patient stability
i. Check EKG for rhythm changes (bradycardia due to heart block)
ii. Check angio to evaluate PVL
iii. Check echo to evaluate PVL and mitral interaction
iv. Check BP
b. If no PVL/conduction disturbance/mitral interaction»_space; leave in place
c. If valve is still at the level of the skirt»_space; post BAV could help seal in the LVOT
d. If past the skirt and significant PVL»_space; consider a second valve implanted at least one full diamond higher to prevent 2nd valve settling too deep
e. If interfering with mitral apparatus»_space; use two snares to grab paddles and stabilize the valve and pull TAV aortic
i. Be aware of risk of aortic dissection, stroke, or valve embolization
ii. Snare TAV to ascending aorta and prep second valve/implant BEV
iii. If unable to snare, may need to convert to surgery
Suicide Ventricle
Hypotension after final deployment
a. Check EKG for rhythm changes or ST segment changes
b. Check coronaries and PVL via angiography
c. Check echo
i. Look at TAV leaflet coaptation, valve depth, PVL, pericardial effusion, mitral valve interaction, LV function
ii. Will see hyperdynamic LV with free wall and septum touching during systole
1. Higher risk if EF > 70% or small LV
d. Push IV fluids to increase volume into LV
e. Do not give medications that increase contractility (ie. epi/dobutamine/dopamine)
