Cause of Complete Atrioventricular Block After Percutaneous Aortic Valve Implantation
2009; Lippincott Williams & Wilkins; Volume: 120; Issue: 5 Linguagem: Inglês
10.1161/circulationaha.109.849281
ISSN1524-4539
AutoresRaúl Moreno, David Dobarro, Esteban López de Sá, Mario Prieto, Carmen Morales, Luís Calvo Orbe, Isidro Moreno‐Gómez, David Filgueiras‐Rama, Ángel Sánchez‐Recalde, Guillermo Galeote, Santiago Jiménez‐Valero, J L López-Sendón,
Tópico(s)Cardiac pacing and defibrillation studies
ResumoHomeCirculationVol. 120, No. 5Cause of Complete Atrioventricular Block After Percutaneous Aortic Valve Implantation Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBCause of Complete Atrioventricular Block After Percutaneous Aortic Valve ImplantationInsights From a Necropsy Study Raul Moreno, MD, David Dobarro, MD, Esteban López de Sá, MD, Mario Prieto, MD, Carmen Morales, MD, Luis Calvo Orbe, MD, Isidro Moreno-Gomez, MD, David Filgueiras, MD, Angel Sanchez-Recalde, MD, Guillermo Galeote, MD, Santiago Jiménez-Valero, MD and José-Luis Lopez-Sendon, MD Raul MorenoRaul Moreno From the Department of Cardiology (R.M., D.D., E.L.d.S., L.C.O., D.F., A.S.-R., G.G., S.J.-V., J.-L.L.-S.), Department of Pathology (M.P., C.M.), and Unit of Cardiothoracic Anesthesia (I.M.-G.). University Hospital La Paz, Madrid, Spain. , David DobarroDavid Dobarro From the Department of Cardiology (R.M., D.D., E.L.d.S., L.C.O., D.F., A.S.-R., G.G., S.J.-V., J.-L.L.-S.), Department of Pathology (M.P., C.M.), and Unit of Cardiothoracic Anesthesia (I.M.-G.). University Hospital La Paz, Madrid, Spain. , Esteban López de SáEsteban López de Sá From the Department of Cardiology (R.M., D.D., E.L.d.S., L.C.O., D.F., A.S.-R., G.G., S.J.-V., J.-L.L.-S.), Department of Pathology (M.P., C.M.), and Unit of Cardiothoracic Anesthesia (I.M.-G.). University Hospital La Paz, Madrid, Spain. , Mario PrietoMario Prieto From the Department of Cardiology (R.M., D.D., E.L.d.S., L.C.O., D.F., A.S.-R., G.G., S.J.-V., J.-L.L.-S.), Department of Pathology (M.P., C.M.), and Unit of Cardiothoracic Anesthesia (I.M.-G.). University Hospital La Paz, Madrid, Spain. , Carmen MoralesCarmen Morales From the Department of Cardiology (R.M., D.D., E.L.d.S., L.C.O., D.F., A.S.-R., G.G., S.J.-V., J.-L.L.-S.), Department of Pathology (M.P., C.M.), and Unit of Cardiothoracic Anesthesia (I.M.-G.). University Hospital La Paz, Madrid, Spain. , Luis Calvo OrbeLuis Calvo Orbe From the Department of Cardiology (R.M., D.D., E.L.d.S., L.C.O., D.F., A.S.-R., G.G., S.J.-V., J.-L.L.-S.), Department of Pathology (M.P., C.M.), and Unit of Cardiothoracic Anesthesia (I.M.-G.). University Hospital La Paz, Madrid, Spain. , Isidro Moreno-GomezIsidro Moreno-Gomez From the Department of Cardiology (R.M., D.D., E.L.d.S., L.C.O., D.F., A.S.-R., G.G., S.J.-V., J.-L.L.-S.), Department of Pathology (M.P., C.M.), and Unit of Cardiothoracic Anesthesia (I.M.-G.). University Hospital La Paz, Madrid, Spain. , David FilgueirasDavid Filgueiras From the Department of Cardiology (R.M., D.D., E.L.d.S., L.C.O., D.F., A.S.-R., G.G., S.J.-V., J.-L.L.-S.), Department of Pathology (M.P., C.M.), and Unit of Cardiothoracic Anesthesia (I.M.-G.). University Hospital La Paz, Madrid, Spain. , Angel Sanchez-RecaldeAngel Sanchez-Recalde From the Department of Cardiology (R.M., D.D., E.L.d.S., L.C.O., D.F., A.S.-R., G.G., S.J.-V., J.-L.L.-S.), Department of Pathology (M.P., C.M.), and Unit of Cardiothoracic Anesthesia (I.M.-G.). University Hospital La Paz, Madrid, Spain. , Guillermo GaleoteGuillermo Galeote From the Department of Cardiology (R.M., D.D., E.L.d.S., L.C.O., D.F., A.S.-R., G.G., S.J.-V., J.-L.L.-S.), Department of Pathology (M.P., C.M.), and Unit of Cardiothoracic Anesthesia (I.M.-G.). University Hospital La Paz, Madrid, Spain. , Santiago Jiménez-ValeroSantiago Jiménez-Valero From the Department of Cardiology (R.M., D.D., E.L.d.S., L.C.O., D.F., A.S.-R., G.G., S.J.-V., J.-L.L.-S.), Department of Pathology (M.P., C.M.), and Unit of Cardiothoracic Anesthesia (I.M.-G.). University Hospital La Paz, Madrid, Spain. and José-Luis Lopez-SendonJosé-Luis Lopez-Sendon From the Department of Cardiology (R.M., D.D., E.L.d.S., L.C.O., D.F., A.S.-R., G.G., S.J.-V., J.-L.L.-S.), Department of Pathology (M.P., C.M.), and Unit of Cardiothoracic Anesthesia (I.M.-G.). University Hospital La Paz, Madrid, Spain. Originally published4 Aug 2009https://doi.org/10.1161/CIRCULATIONAHA.109.849281Circulation. 2009;120:e29–e30Transcatheter aortic valve implantation is being established as an alternative treatment for some patients with symptomatic severe aortic stenosis who are not considered suitable for surgical aortic valve replacement because of prohibitive surgical risk.1–3 One of the potential complications is complete atrioventricular block requiring definitive pacemaker implantation. This complication occurs in 4% to 5% with the Edwards-Sapiens prosthesis (Edwards Lifesciences, Irvine, Calif),1 and in >30% with the CoreValve system (Medtronic CV, Luxembourg),3 but it also occurs in 5% of patients after percutaneous aortic valvuloplasty4 or surgical aortic valve replacement.5The cause of complete atrioventricular block after transcatheter aortic valve implantation is unknown. Apart from traumatic lesions produced by aortic valve prosthesis expansion, ischemia of the conduction pathways resulting from insufficient myocardial protection might play a role. Here, necropsy findings in a patient with complete atrioventricular block after transcatheter aortic valve implantation are presented for the first time, showing the physiopathology of this complication.A 79-year-old woman with symptomatic severe aortic stenosis and prohibitive surgical risk was referred for transcatheter aortic valve implantation. A 26-mm Edwards-Sapiens prosthetic valve was implanted without complications except complete atrioventricular block requiring transvenous pacemaker stimulation. Three days after transcatheter aortic valve implantation, the patient suffered sudden cardiac death that could not be resolved with resuscitation. Necropsy was performed to evaluate the status of the prosthetic valve and to gain potential insights into the cause of the atrioventricular block.Necropsy found right ventricular perforation as the cause of death. Autopsy of the right ventricle showed a localized area of necrosis and hematoma in the right ventricular wall with communication between the right ventricular cavity and pericardial space produced by the pacemaker electrode. The aortic valve prosthesis was well expanded and apposed to the aortic annulus (Figure, A). Pathological macroscopic study showed also a localized hematoma at the interventricular septum at the site of aortic valve prosthesis expansion (Figure, B). This area was studied histologically. Compression of the bundle of His by this localized hematoma at the interventricular septum was found (Figure, C and D). It is possible that the mechanical effect of this hematoma over the bundle of His has been exaggerated by the pathological process caused by ageing and amyloid deposits at the myocardium found in this patient, resulting in interruption of the atrioventricular conduction system to produce complete atrioventricular block. Download figureDownload PowerPointFigure. A, View of the aortic root. The Edwards-SAPIEN prosthetic valve is correctly implanted. The path of one of the coronary arteries is shown. B, As the prosthesis was removed from the aortic outflow tract, some hemorrhagic lesions were observed, as well as calcifications of native aortic valves and severe calcification of the mitral valve, which appears as a yellowish nodule. In the upper interventricular septum, a subendocardiac hemorrhage is patent. C, From an anatomopathological point of view, we can observe (from left to right) the endocardium, a hemorrhagic band next to the bundle of His (*), an amyloid deposit, and myocardial fibers (▴) (hematoxylin and eosin, ×10). D, In an enlarged image, we can see conduction tissue fibers made up of specialized myocytes with central glycogen deposits that produce a myocardial fiber displacement to the periphery. Hematic extravasation next to those fibers is evident (hematoxylin and eosin, ×40).AcknowledgmentsThe authors would like to thank Isabel Muñoz from Edwards LifeSciences.DisclosuresNone.FootnotesCorrespondence to Raul Moreno, MD, FESC, Director of Interventional Cardiology, University Hospital La Paz, Paseo La Castellana, 261, 28046 Madrid, Spain. E-mail [email protected]References1 Webb JG, Pasupati S, Humphries K, Thompson C, Altwegg L, Moss R, Sinhal A, Carere RG, Munt B, Ricci D, Ye J, Cheung A, Lichtenstein SV. Percutaneous transarterial aortic valve replacement in selected high-risk patients with aortic stenosis. Circulation. 2007; 116: 755–763.LinkGoogle Scholar2 Moreno R, Calvo L, Filgueiras D, Lopez T, Sanchez-Recalde A, Jimenez-Valero S, Galeote G, Lopez-Sendon JL. Implantación percutánea de prótesis valvular aórtica en pacientes com estenosis aórtica severa rechazados para cirugía. Rev Esp Cardiol. 2008; 61: 1215–1219.CrossrefMedlineGoogle Scholar3 Grube E, Schuler G, Buellesfeld L, Gerckens U, Linke A, Wenaweser P, Sauren B, Mohr FW, Walther T, Zickmann B, Iversen S, Felderhoff T, Cartier R, Bonan R. Percutaneous aortic valve replacement for severe aortic stenosis in high-risk patients using the second and current third generation self-expanding CoreValve prosthesis. J Am Coll Cardiol. 2007; 50: 69–76.CrossrefMedlineGoogle Scholar4 Serruys PW, Luijten HE, Beatt KJ, Di Mario C, de Feyter PJ, Essed CE, Roelandt JR, van den Brand M. 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