Abstract 4369914: Successful Transfemoral TAVR in a Patient with Chronic Aortic Dissection and Severe Aortic Insufficiency

Transcatheter aortic valve replacement is a well-established treatment for high-surgical-risk patients with severe aortic disease, providing a less invasive alternative to traditional surgery. While TAVR has been widely studied, few cases describe its use in patients with complex conditions like chronic aortic dissection and the case presentation below describes a successful case. A 68-year-old female with a history of hypertension, atrial flutter, and persistent type B aortic dissection, status post open repair, presented with worsening dyspnea. She also had moderate-to-severe aortic valve insufficiency. An echocardiogram showed severe regurgitation, aortic valve area of 1.9 and left ventricular dysfunction EF 50%. Cardiac catheterization revealed no significant coronary artery disease. CT imaging showed a complex aortic anatomy with both a true and false lumen extending from the distal ascending aorta into the abdominal aorta. Given her frailty and the complexity of her anatomy, a transfemoral approach for TAVR was chosen over surgical aortic valve replacement or other methods. The procedure was conducted under general anesthesia with primary access via the right common femoral artery and secondary access via the right radial artery. After heparinization, a 6-French pigtail catheter was placed in the aortic root. The valve delivery system (Medtronic Evolute Pro 29 mm valve) was carefully advanced across the aortic valve. During valve deployment, the procedure was complicated by the valve dislodging into the ascending aorta, causing the patient to enter cardiogenic shock. This required immediate pressor support and cardiopulmonary resuscitation. After stabilization, the valve was recaptured and redeployed successfully. Post-deployment imaging, including aortography and echocardiogram, showed proper valve placement, a trace paravalvular leak, an AV peak gradient of 10 mmHg, and an estimated aortic valve area of 2.2. Clinical course was complicated by complete heart block requiring a permanent pacemaker. A follow-up echocardiogram confirmed that the bioprosthetic valve was well-seated, with mild paravalvular leakage. TAVR is a less invasive option for high-risk patients with severe aortic disease but presents unique challenges in chronic aortic dissection, especially the risk of stroke due to lack of embolic protection. In this case, the Medtronic Evolute Pro valve was successfully used, highlighting the need for improved embolic protection strategies.