Iatrogenic membranous ventricular septal defects (IVSD) are a rare complication of transcatheter aortic valve implantation (TAVI), mainly attributed to post-dilation and excessive calcification in the left ventricular outflow tract (LVOT). We report a case of IVSD following implantation of an Edwards SAPIEN 3 transcatheter heart valve (Edwards Lifesciences, Irvine, CA, USA) which was successfully treated by a valve-in-valve procedure.
A 79-year-old male with heavily calcified aortic valve and calcification in the LVOT underwent TAVI. Following predilatation, a 29 mm SAPIEN 3 prosthesis was deployed uneventfully. Over the next 12 hours the patient developed right ventricular failure. Echocardiography showed an IVSD with a haemodynamically relevant left-to-right shunt. CT revealed that the prosthesis lying at the upper rim of calcification spots in the LVOT had caused a tear along the calcification. Since the patient deteriorated over the following eight hours, a second 26 mm SAPIEN 3 prosthesis was implanted uneventfully at a lower position within the LVOT to close the IVSD. Transoesophageal echocardiography (TEE) revealed a minimal residual IVSD, no paravalvular leak (PVL) and ∆Pmean=5 mmHg. Due to postoperative 3rd degree atrioventricular (AV) block, a pacemaker was implanted. A transthoracic echocardiogram (TTE) after two months showed persistent minimal IVSD jet. Left and right ventricular function were preserved and the patient was asymptomatic.
Conflict of interest statement
T. Rudolph, S. Baldus, T. Wahlers and N. Mader are proctors for Edwards Lifesciences. The other authors have no conflicts of interest to declare.
Supplementary data
Online Figure 1. CT and echocardiographic images.
Online Figure 1. CT and echocardiographic images. A) Preoperative CT scan revealed a symmetrically severely calcified aortic valve and two prominent spike-like calcifications in the LVOT (B). C) Final position of the SAPIEN 3 (29 mm). D) Postoperative TTE and TEE (E) showed an IVSD with significant left-to-right shunt. F) Prosthesis at the upper rim of LVOT calcification (CT scan). G) After implanting the second SAPIEN 3 (26 mm), intraoperative TEE revealed a minimal residual IVSD jet. H) Small jet from the left into the right ventricle at two-month follow-up.
