Delayed aortic regurgitation after TEVAR procedure: a case report

(2022) 17:336 Park et al. Journal of Cardiothoracic Surgery https://doi.org/10.1186/s13019-022-02083-3 Open Access CASE REPORT Delayed aortic regurgitation after TEVAR procedure: a case report Soo Jin Park1, Seungwook Lee2, Jeong A Son2, Seungji Hyun2, Do Jung Kim2, Sang Hyun Lim2 and You Sun Hong2* Abstract Background: Acute aortic regurgitation (AR) is uncommon condition and usually results in an emergent situation because the left ventricle does not adapt quickly due to a sudden increase in end-diastolic volume caused by the regurgitant flow. Thoracic endovascular aortic repair (TEVAR) is a procedure that places a stent-graft on the lesion of thoracic aorta through a minimally invasive approach. Case presentation: Here we report that a catheter-induced aortic valve injury associated with TEVAR can cause delayed AR, exemplified by the case of a patient who developed acute AR 42 months after TEVAR. For this, aortic valve replacement was performed and the patient was discharged without complications. Conclusion: Our results demonstrate that when a catheter-related procedure is performed around the aortic valve, slight injury of the valve can cause aortic insufficiency even 3 years after surgery. Consequently, when performing a catheter-related procedure around the aortic valve, special attention is always required. Keywords: Aortic regurgitation, Catheter induced injury, Thoracic endovascular aortic repair (TEVAR) Background Aortic regurgitation (AR) is the diastolic regurgitation of blood from the aorta into the left ventricle (LV) through a dysfunctional aortic valve [1]. Acute AR is uncommon and may result from type A aortic dissection, endocarditis or trauma, and less commonly iatrogenic causes [2]. Acute severe aortic regurgitation usually results in an emergent situation because the left ventricle does not adapt quickly due to a sudden increase in end-diastolic volume caused by regurgitant flow [2]. If not surgically corrected, cardiogenic shock may be induced. Thoracic endovascular aortic repair (TEVAR) is a procedure that places a stent-graft on the lesion through a minimally invasive approach in various pathology *Correspondence: 2 Department of Thoracic and Cardiovascular Surgery, Ajou University School of Medicine, 164, Worldcup‑ro, Yeongtong‑gu, Suwon 16499, Korea Full list of author information is available at the end of the article situations of thoracic aorta and thoracoabdominal aorta [3]. TEVER is recommended for saccular aneurysm that occurs in the isthmus portion of the aorta after trauma [4]. We would like to report that catheter-induced aortic valve injury used during TEVAR can cause delayed aortic regurgitation through a case of a patient who had acute aortic regurgitation 42 months after TEVAR and was discharged after performing surgical aortic valve replacement. Case presentation The 58-year-old male patient visited a local hospital for traffic accident by bicycle and was transferred to this medical institution with isthmus portion saccular dissection of descending thoracic aorta (Fig. 1 A–C) and performed aortic stent graft insertion (Fig. 1D, Additional file : 1). Briefly, after ultrasound-guided femoral puncture, a Lunderquist extra-stiff wire (Cook Medical, © The Author(s) 2022. 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The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Park et al. Journal of Cardiothoracic Surgery (2022) 17:336 Page 2 of 5 Fig. 1 Computed tomography of aorta and aortogram of patient and aortogram performed after stent graft insertion. A 3D reconstruction image of patient’s aorta computed tomography. B Sagittal image of patient’s aorta computed tomography. C Aortogram of patient’s aorta. D Aortogram performed after stent graft insertion. White arrow indicates saccular dissection of descending thoracic aorta Bloomington, IN, USA) was introduced. Then, a stent graft (Valiant Captivia; 32–28 mm, tapered; length: 1150 mm; Medtronic, Minneapolis, MN, USA) was inserted along the pre-inserted wire. On the 7th day after the procedure, F/U aorta CT showed no endo-leakage of the stent graft and was discharged without any special complications. During the outpatient follow-up, no unusual findings were observed at 3 months, 9 months, 15 months, and 27 months follow-up. Severe aortic regurgitation with flail aortic valve movement (right coronary cusp), which was not observed when TEVAR treatment (Fig. 2 A–B, Additional file : 2), was observed on an echocardiogram performed through the emergency room of the hospital due to sudden dyspnea 42 months after the stent graft operation (Fig. 2 C–D, Additional file : 3). Resected sharp margin of the right coronary cusp was observed in the aortic valve during surgery (Fig. 3 A–B). For this, aortic valve replacement (Edwards tissue aortic valve#23mm) was performed and the patient was discharged on the 8th day of POD without any special complications. Discussion and conclusions TEVER was initially attempted in a situation where it could not be a surgical candidate, but as the procedure technique and materials have been developed, it Park et al. Journal of Cardiothoracic Surgery (2022) 17:336 Page 3 of 5 Fig. 2 Echocardiograms performed at the time of aorta injury and 42 months after stent graft insertion. A–B An echocardiogram performed on the fourth day after TEVAR (EF 61%, LVEDD/LVESD 51/34mm, LA 40 mm, LV mass index 107.5 g/m2, Aortic annulus/Sinus valsalva/Sinotubular junction/Ascending aorta 22 mm/38mm/31mm/38mm, Trivial MR, Trivial TR). C–D An echocardiogram performed at the emergency room for sudden dyspnea 42 months after stent graft insertion (EF 63%, LVEDD/LVESD 90/46mm, LA 59 mm, LV mass index 169.7 g/m2, Aortic annulus/Sinus valsalva/Sinotubular junction/Ascending aorta 22 mm/35mm/27mm/ 40 mm, AR grade 4, MR grade 1, Trivial TR). (EF Ejection fraction, LVEDD Left ventricular end diastolic dimension, LVESD Left ventricular end systolic dimension, LA Left atrium, LV Left ventricle, MR Mitral valve regurgitation, TR (...truncated)