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central aortic regurgitation related to TAVR has not often been reported&#44; as it is usually associated with overdilatation after implantation when the valve is too small or when reducing PAR&#46; To our knowledge&#44; central prosthetic aortic regurgitation due to acute left ventricular &#40;LV&#41; dysfunction has not been described&#44; and should be borne in mind in perioperative echocardiography&#44; to identify a possible reversible cause of this phenomenon&#46; We present a case reflecting these issues&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">We present the case of an 82-year-old hypertensive woman&#46; Five years previously&#44; percutaneous transluminal coronary angioplasty had been performed due to occlusion of the mid left anterior descending artery &#40;LAD&#41;&#44; and two Cypher stents&#44; 3&#47;33 mm and 2&#46;5&#47;28 mm&#44; were implanted&#46; In the previous year she had symptoms of effort angina and grade 3 dyspnea&#46; The LAD stents were in good condition and no other lesions were observed&#46; Severe aortic stenosis was observed with aortic valve area 0&#46;75 cm<span class="elsevierStyleSup">2</span>&#44; peak gradient 80 mmHg and normal LV function with severe hypertrophy&#46; The EuroSCORE for this patient was 20&#37;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Aortic annulus diameter was 21 mm and right femoral artery diameter was 7&#46;7 mm&#46; The patient was scheduled for TAVR&#46; During the implantation of a 23 mm Edwards SAPIEN X T valve&#44; sudden severe LV dysfunction occurred with posterior-inferior akinesis and acute severe mitral regurgitation&#46; Moderate central aortic prosthetic regurgitation was observed on aortography &#40;appearing lighter on Doppler echocardiography&#41; &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figures 1 and 2</a>&#41;&#46; Emergency coronary catheterization showed an acute occlusion of the mid right coronary artery &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; A thrombus was aspirated using a Pronto extraction catheter &#40;Vascular Solutions&#44; Minneapolis&#44; MN&#44; USA&#41;&#46; Its shape suggested that it had been released from the pigtail catheter in the ascending aorta&#44; even though heparin 100 U&#47;kg had been administered and activated clotting time was 250 s &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; As soon as the right coronary artery was opened and TIMI 3 flow was restored&#44; LV function recovered completely and the mitral regurgitation almost disappeared&#44; returning to baseline status &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figures 2 and 3</a>&#41;&#46; Repeat aortography showed resolution of central prosthetic aortic valve regurgitation &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figures 1 and 2</a>&#41;&#46; The patient progressed without problems&#44; with minimal troponin elevation and continuing normal LV function&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Periprosthetic aortic regurgitation or paravalvular leaks and their repercussions on prognosis are well known&#44;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#8211;4</span></a> but acute central aortic regurgitation during TAVR secondary to acute LV dysfunction is a lesser-known phenomenon that resolves after acute improvement of LV function&#46; The importance is in being aware of the problem&#44; and having in mind that transient ventricular dysfunction might be the cause of regurgitation&#59; this is reversible and different from aortic regurgitation due to overdilatation&#44; in which case the mechanism is inadequate leaflet coaptation&#46; The mechanisms of prosthetic regurgitation in the situation described are not well understood&#44; but are probably related to hypotension secondary to acute LV failure&#44; which causes poor leaflet coaptation&#59; the valves need adequate systolic pressure to open and a certain diastolic pressure to close correctly&#44; or a minimum gradient between aortic diastolic pressure &#40;which was low in this case&#41; and LV diastolic pressure &#40;high at the time of occlusion in this case&#41;&#46; The patient&#39;s blood pressure was 50&#47;30 mmHg&#46; Moreover&#44; acute ischemic mitral regurgitation is well known and is frequently associated with papillary muscle ischemia&#46; Regarding coronary occlusion due to embolism&#44; the thrombus could have originated from the catheter or a clot attached to the prosthesis&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> Cases in which embolism is caused by materials swept from the aorta are also described&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> In our case&#44; the thrombus shape suggested that its origin was in the catheter&#46; Aspiration opened the coronary immediately and there was no need to place a stent&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion&#44; periprosthetic aortic regurgitation or paravalvular leak is a well-known condition after TAVR&#46; However&#44; central regurgitation after TAVR has received less attention&#44; as a rare case usually associated with the guide remaining through the valves during the procedure&#44; or to overdilatation aimed at preventing paravalvular leak&#46; Our case shows that central regurgitation may also occur after &#40;usually ischemic&#41; acute LV dysfunction and that the situation&#44; if not the original condition&#44; is reversible&#46; Additionally&#44; this can be a guiding sign to rule out unsuspected acute dysfunction&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Transcatheter aortic valve replacement &#40;TAVR&#41; is an increasingly common procedure for the treatment of aortic stenosis in elderly patients with comorbidities that prevent the use of standard surgery&#46; It has been shown that implantation without aortic regurgitation is related to lower mortality&#46; Mild paravalvular regurgitation is inevitable in some cases due to calcification of the aortic annulus and its usually somewhat elliptical shape&#46; Central regurgitation is less common&#44; but has been associated with valve overdilatation in cases in which reduction of paravalvular regurgitation was attempted after the initial inflation&#46; However&#44; there are no reported cases of central prosthetic aortic regurgitation due to acute LV dysfunction&#46; We report a case in which central aortic regurgitation occurred due to transient ventricular dysfunction secondary to occlusion of the right coronary artery by an embolus&#46; The regurgitation disappeared after thrombus aspiration and normal ventricular function was immediately recovered&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A substitui&#231;&#227;o percut&#226;nea de v&#225;lvula a&#243;rtica &#40;<span class="elsevierStyleItalic">transcatheter aortic valve replacement &#8211;</span> TAVR&#41; tem-se tornado cada vez mais frequente para o tratamento da estenose a&#243;rtica em pacientes idosos com doen&#231;as associadas&#44; para evitar a cirurgia convencional&#46; Sabe-se que&#44; n&#227;o havendo refluxo a&#243;rtico ap&#243;s o implante&#44; a mortalidade ser&#225; mais baixa&#46; Em alguns casos&#44; contudo&#44; um refluxo paravalvular moderado &#233; inevit&#225;vel&#44; devido &#224; calcifica&#231;&#227;o do &#226;nulo-a&#243;rtico e &#224; sua configura&#231;&#227;o geralmente el&#237;ptica&#46; O refluxo central &#233; mais raro&#44; tendo sido associado &#224; excessiva dilata&#231;&#227;o da v&#225;lvula em casos em que se tentou redu&#231;&#227;o do refluxo paravalvular&#44; ap&#243;s a infla&#231;&#227;o inicial&#46; Entretanto&#44; n&#227;o foram referidos casos de refluxo a&#243;rtico central por disfun&#231;&#227;o ventricular esquerda aguda&#46; Referimos um caso em que ocorreu refluxo a&#243;rtico central por disfun&#231;&#227;o ventricular transit&#243;ria&#44; secund&#225;ria &#224; oclus&#227;o da art&#233;ria coron&#225;ria direita por &#234;mbolo&#46; O refluxo desapareceu ap&#243;s aspira&#231;&#227;o do trombo&#44; sendo recuperada imediatamente a fun&#231;&#227;o ventricular normal&#46;</p></span>"
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Case report
Unusual cause of central aortic prosthetic regurgitation during transcatheter replacement
Causa rara de refluxo central durante a substituição percutânea de válvula aórtica
José Ramón López-Mínguez
Autor para correspondência
lopez-minguez@hotmail.com

Corresponding author.
, Victoria Millán-Núñez, Reyes González-Fernández, Juan Manuel Nogales-Asensio, María Eugenia Fuentes-Cañamero, Antonio Merchán-Herrera
Hospital Universitario Infanta Cristina, Badajoz, Spain
Lido
6254
Vezes
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of cases in both studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#44;2</span></a> Minimal PAR was observed in 46&#37; according to the meta-analysis&#46; Three factors have been identified as predictors of PAR after TAVR&#58; prosthetic valve undersizing&#44; improper implantation depth and aortic valve calcification&#46; The importance of this issue is that moderate or severe regurgitation has been associated with increased mortality at both 30 days and one year&#59; mild regurgitation has been linked to higher mortality&#44; although this is only a tendency in some studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#8211;4</span></a> On the basis of current data&#44; some reports have emphasized the importance of selecting the most appropriate prosthesis size using imaging techniques such as computed tomography&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">However&#44; central aortic regurgitation related to TAVR has not often been reported&#44; as it is usually associated with overdilatation after implantation when the valve is too small or when reducing PAR&#46; To our knowledge&#44; central prosthetic aortic regurgitation due to acute left ventricular &#40;LV&#41; dysfunction has not been described&#44; and should be borne in mind in perioperative echocardiography&#44; to identify a possible reversible cause of this phenomenon&#46; We present a case reflecting these issues&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">We present the case of an 82-year-old hypertensive woman&#46; Five years previously&#44; percutaneous transluminal coronary angioplasty had been performed due to occlusion of the mid left anterior descending artery &#40;LAD&#41;&#44; and two Cypher stents&#44; 3&#47;33 mm and 2&#46;5&#47;28 mm&#44; were implanted&#46; In the previous year she had symptoms of effort angina and grade 3 dyspnea&#46; The LAD stents were in good condition and no other lesions were observed&#46; Severe aortic stenosis was observed with aortic valve area 0&#46;75 cm<span class="elsevierStyleSup">2</span>&#44; peak gradient 80 mmHg and normal LV function with severe hypertrophy&#46; The EuroSCORE for this patient was 20&#37;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Aortic annulus diameter was 21 mm and right femoral artery diameter was 7&#46;7 mm&#46; The patient was scheduled for TAVR&#46; During the implantation of a 23 mm Edwards SAPIEN X T valve&#44; sudden severe LV dysfunction occurred with posterior-inferior akinesis and acute severe mitral regurgitation&#46; Moderate central aortic prosthetic regurgitation was observed on aortography &#40;appearing lighter on Doppler echocardiography&#41; &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figures 1 and 2</a>&#41;&#46; Emergency coronary catheterization showed an acute occlusion of the mid right coronary artery &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; A thrombus was aspirated using a Pronto extraction catheter &#40;Vascular Solutions&#44; Minneapolis&#44; MN&#44; USA&#41;&#46; Its shape suggested that it had been released from the pigtail catheter in the ascending aorta&#44; even though heparin 100 U&#47;kg had been administered and activated clotting time was 250 s &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; As soon as the right coronary artery was opened and TIMI 3 flow was restored&#44; LV function recovered completely and the mitral regurgitation almost disappeared&#44; returning to baseline status &#40;<a class="elsevierStyleCrossRefs" href="#fig0010">Figures 2 and 3</a>&#41;&#46; Repeat aortography showed resolution of central prosthetic aortic valve regurgitation &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figures 1 and 2</a>&#41;&#46; The patient progressed without problems&#44; with minimal troponin elevation and continuing normal LV function&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Periprosthetic aortic regurgitation or paravalvular leaks and their repercussions on prognosis are well known&#44;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#8211;4</span></a> but acute central aortic regurgitation during TAVR secondary to acute LV dysfunction is a lesser-known phenomenon that resolves after acute improvement of LV function&#46; The importance is in being aware of the problem&#44; and having in mind that transient ventricular dysfunction might be the cause of regurgitation&#59; this is reversible and different from aortic regurgitation due to overdilatation&#44; in which case the mechanism is inadequate leaflet coaptation&#46; The mechanisms of prosthetic regurgitation in the situation described are not well understood&#44; but are probably related to hypotension secondary to acute LV failure&#44; which causes poor leaflet coaptation&#59; the valves need adequate systolic pressure to open and a certain diastolic pressure to close correctly&#44; or a minimum gradient between aortic diastolic pressure &#40;which was low in this case&#41; and LV diastolic pressure &#40;high at the time of occlusion in this case&#41;&#46; The patient&#39;s blood pressure was 50&#47;30 mmHg&#46; Moreover&#44; acute ischemic mitral regurgitation is well known and is frequently associated with papillary muscle ischemia&#46; Regarding coronary occlusion due to embolism&#44; the thrombus could have originated from the catheter or a clot attached to the prosthesis&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> Cases in which embolism is caused by materials swept from the aorta are also described&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> In our case&#44; the thrombus shape suggested that its origin was in the catheter&#46; Aspiration opened the coronary immediately and there was no need to place a stent&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion&#44; periprosthetic aortic regurgitation or paravalvular leak is a well-known condition after TAVR&#46; However&#44; central regurgitation after TAVR has received less attention&#44; as a rare case usually associated with the guide remaining through the valves during the procedure&#44; or to overdilatation aimed at preventing paravalvular leak&#46; Our case shows that central regurgitation may also occur after &#40;usually ischemic&#41; acute LV dysfunction and that the situation&#44; if not the original condition&#44; is reversible&#46; Additionally&#44; this can be a guiding sign to rule out unsuspected acute dysfunction&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Transcatheter aortic valve replacement &#40;TAVR&#41; is an increasingly common procedure for the treatment of aortic stenosis in elderly patients with comorbidities that prevent the use of standard surgery&#46; It has been shown that implantation without aortic regurgitation is related to lower mortality&#46; Mild paravalvular regurgitation is inevitable in some cases due to calcification of the aortic annulus and its usually somewhat elliptical shape&#46; Central regurgitation is less common&#44; but has been associated with valve overdilatation in cases in which reduction of paravalvular regurgitation was attempted after the initial inflation&#46; However&#44; there are no reported cases of central prosthetic aortic regurgitation due to acute LV dysfunction&#46; We report a case in which central aortic regurgitation occurred due to transient ventricular dysfunction secondary to occlusion of the right coronary artery by an embolus&#46; The regurgitation disappeared after thrombus aspiration and normal ventricular function was immediately recovered&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A substitui&#231;&#227;o percut&#226;nea de v&#225;lvula a&#243;rtica &#40;<span class="elsevierStyleItalic">transcatheter aortic valve replacement &#8211;</span> TAVR&#41; tem-se tornado cada vez mais frequente para o tratamento da estenose a&#243;rtica em pacientes idosos com doen&#231;as associadas&#44; para evitar a cirurgia convencional&#46; Sabe-se que&#44; n&#227;o havendo refluxo a&#243;rtico ap&#243;s o implante&#44; a mortalidade ser&#225; mais baixa&#46; Em alguns casos&#44; contudo&#44; um refluxo paravalvular moderado &#233; inevit&#225;vel&#44; devido &#224; calcifica&#231;&#227;o do &#226;nulo-a&#243;rtico e &#224; sua configura&#231;&#227;o geralmente el&#237;ptica&#46; O refluxo central &#233; mais raro&#44; tendo sido associado &#224; excessiva dilata&#231;&#227;o da v&#225;lvula em casos em que se tentou redu&#231;&#227;o do refluxo paravalvular&#44; ap&#243;s a infla&#231;&#227;o inicial&#46; Entretanto&#44; n&#227;o foram referidos casos de refluxo a&#243;rtico central por disfun&#231;&#227;o ventricular esquerda aguda&#46; Referimos um caso em que ocorreu refluxo a&#243;rtico central por disfun&#231;&#227;o ventricular transit&#243;ria&#44; secund&#225;ria &#224; oclus&#227;o da art&#233;ria coron&#225;ria direita por &#234;mbolo&#46; O refluxo desapareceu ap&#243;s aspira&#231;&#227;o do trombo&#44; sendo recuperada imediatamente a fun&#231;&#227;o ventricular normal&#46;</p></span>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Aortography with mild to moderate regurgitation &#40;arrows&#41; through the prosthetic aortic valve&#59; &#40;B&#41; aortography showing resolution of regurgitation after removal of thrombus from the right coronary artery &#40;CA&#41; &#40;due to immediate improvement of left ventricular function seen on transesophageal echocardiography&#41;&#59; &#40;C&#41; acute thrombotic occlusion in the mid third of the RCA&#59; &#40;D&#41; RCA with TIMI 3 flow after extraction of the thrombus&#59; &#40;E&#41; thrombus extracted from the RCA after aspiration with the Pronto device&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Deep transgastric view at 0&#176;&#58; mild central aortic regurgitation &#40;arrows&#41; during acute ischemia and acute severe LV dysfunction&#59; &#40;B&#41; deep transgastric view at 0&#176;&#58; disappearance of aortic regurgitation after resolution of ischemia and immediate improvement of left ventricular function&#59; &#40;C&#41; mid-esophageal view at 120&#176;&#58; mild central aortic regurgitation &#40;arrows&#41; during acute ischemia&#59; &#40;D&#41; mid-esophageal view at 120&#176;&#58; scarcely any traces of aortic regurgitation after resolution of ischemia&#46;</p>"
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ISSN: 08702551
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