1. Circ Cardiovasc Interv
Rupture of the Device Landing Zone During Transcatheter Aortic Valve Implantation
by Miralem Pasic, Axel Unbehaun, Stephan Dreysse, Semih Buz, Thorsten Drews, Marian Kukucka, Giuseppe D'Ancona, Burkhardt Seifert, and Roland Hetzer
Circ Cardiovasc Interv
Volume 5(3):
June 19, 2012
Copyright © American Heart Association, Inc. All rights reserved.

2. Identification of the differences in the shapes of the ascending aorta helps in making the decision to use a larger or a smaller prosthesis in borderline situations.
Identification of the differences in the shapes of the ascending aorta helps in making the decision to use a larger or a smaller prosthesis in borderline situations. More pronounced sinuses of Valsalva in comparison with the mid portion of the proximal aorta (“female-shaped,” A) would incline toward the use of a larger prosthesis and less pronounced sinuses of Valsalva (“male-shaped” aorta, B) toward a smaller prosthesis.
Miralem Pasic et al. Circ Cardiovasc Interv. 2012;5:
Copyright © American Heart Association, Inc. All rights reserved.

3. Transapical valve implantation in patient 2 with a small aortic annulus and calcified aortic root.
Transapical valve implantation in patient 2 with a small aortic annulus and calcified aortic root. Stopping the balloon inflation and incomplete dilation of the Edwards-Sapien prosthesis at this stage (A) would have prevented the annulus rupture shown in D. Note overdistension of the aorta (yellow arrows) by complete inflation of the balloon during valve deployment (B). Angiography was performed immediately after valve deployment to find the cause of failed myocardial recovery after valve deployment; contrast instillation through a pigtail catheter above the new valve showed no coronary artery occlusion and unusual tilting of the prosthesis below the ostium of the left coronary artery but no extravasation of the contrast is seen at this stage. A superstiff guide wire is still in place (C). An attempt at selective angiographic visualization of the left coronary artery (LCA) showed rupture of the left coronary sinus of Valsalva including the ostium of the LCA and extraluminal contrast extravasation (red arrows) in the region between the proximal aorta, LCA, and the trunk of the pulmonary artery (D). Note the venous cannula for emergency cardiopulmonary bypass. Ao indicates ascending aorta; LVOT, left ventricular outflow tract; and RCA, right coronary artery.
Miralem Pasic et al. Circ Cardiovasc Interv. 2012;5:
Copyright © American Heart Association, Inc. All rights reserved.

4. Intraprocedural transesophageal echocardiography (A, aortic valve short-axis view; B, aortic valve long-axis view) showing para-aortic hematoma (red circle) after implantation of an Edwards-Sapien valve in patient 2.
Intraprocedural transesophageal echocardiography (A, aortic valve short-axis view; B, aortic valve long-axis view) showing para-aortic hematoma (red circle) after implantation of an Edwards-Sapien valve in patient 2. The hematoma is located in the region of the proximal left coronary artery and between the left posterior side of the proximal aorta and the left atrium (LA) and the pulmonary artery (PA). This finding correlated to the contrast extravasation seen in Figure 1D. Ao indicates ascending aorta; LVOT, left ventricular outflow tract; r PA, right pulmonary artery; and RV, right ventricle.
Miralem Pasic et al. Circ Cardiovasc Interv. 2012;5:
Copyright © American Heart Association, Inc. All rights reserved.

5. Regular angiography after valve deployment in patient 3 was initially—wrongly—assessed as normal.
Regular angiography after valve deployment in patient 3 was initially—wrongly—assessed as normal. After slight bleeding appeared with no identifiable cause, reevaluation of the angiographic examination showed pathological findings barely seen at the end of angiography that were initially not recognized by the transcatheter aortic valve implantation team. Early phase of angiography (A) shows normal findings after implantation of an Edwards-Sapien valve. In the late phase (B) there is a flaw and irregular periaortal extravasation of the contrast (yellow arrows) after annulus rupture und lesion of the calcified right coronary sinus of Valsalva. Red arrow shows the site of contrast leakage below the right coronary artery. LCA indicates left coronary artery; LVOT, left ventricular outflow tract; and RCA, right coronary artery.
Miralem Pasic et al. Circ Cardiovasc Interv. 2012;5:
Copyright © American Heart Association, Inc. All rights reserved.

6. Computed tomography (A) and preprocedural angiography (B) in patient 4 showing a calcification in the left ventricular outflow tract (LVOT, yellow arrow [A], red circle [B]) immediately below the native aortic valve annulus in the region of the left coronary sinus of Valsalva.
Computed tomography (A) and preprocedural angiography (B) in patient 4 showing a calcification in the left ventricular outflow tract (LVOT, yellow arrow [A], red circle [B]) immediately below the native aortic valve annulus in the region of the left coronary sinus of Valsalva. Completion angiography after valve deployment showed an optimal position of the new transcatheter valve and a finding of an unusual small amount of contrast in the region of the aortoventricular connection below the left coronary artery (C, yellow circle). The patient was treated conservatively. Ao indicates ascending aorta; LM. main trunk of the left coronary artery; LV, left ventricle; and RCA, right coronary artery.
Miralem Pasic et al. Circ Cardiovasc Interv. 2012;5:
Copyright © American Heart Association, Inc. All rights reserved.

7. Angiography after valve deployment showing annulus rupture (yellow circle) with contrast extravasation (red circle) below the left coronary artery (LCA) with propagation into the adjacent left ventricular myocardium in patient 6.
Angiography after valve deployment showing annulus rupture (yellow circle) with contrast extravasation (red circle) below the left coronary artery (LCA) with propagation into the adjacent left ventricular myocardium in patient 6. LVOT indicates left ventricular outflow tract; RCA, right coronary artery.
Miralem Pasic et al. Circ Cardiovasc Interv. 2012;5:
Copyright © American Heart Association, Inc. All rights reserved.