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CLEAR FILTERS
The TAVI Puzzle: RCA Obstruction, Cardiogenic Shock, and HALT
Session:
CASOS CLÍNICOS DE INTERVENÇÃO (PERCUTÂNEA E CIRÚRGICA)
Speaker:
Andre Lobo
Congress:
CPC 2025
Topic:
H. Interventional Cardiology and Cardiovascular Surgery
Theme:
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Subtheme:
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Session Type:
Sessão de Casos Clínicos
FP Number:
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Authors:
Andre Lobo; Marta Leite; Marta Catarina Almeida; Pedro Gonçalves Teixeira; Marisa Silva; Adelaide Dias; Marta Ponte; Pedro Braga; Cláudio Espada Guerreiro; Rita Faria; Nuno Dias Ferreira; Ricardo Fontes-Carvalho
Abstract
<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-family:"Calibri",sans-serif">We present the case of an 80-year-old female with severe aortic stenosis who underwent successful TAVI using a 25 mm self-expandable bioprosthesis, via right femoral artery access. The procedure was uneventful, and post-procedural TTE confirmed correct positioning and function of the bioprosthesis, with minimal paravalvular regurgitation.</span></span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-family:"Calibri",sans-serif">Approximately three hours after ICU admission, the patient developed chest pain and diaphoresis, followed by complete AV block with hemodynamic compromise. A transvenous temporary pacemaker was promptly placed, achieving a stable pacing rate of 80 beats per minute. Despite pacing, the patient’s condition deteriorated, with persistent hypotension, poor perfusion, and ongoing </span></span></span><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-family:"Calibri",sans-serif">chest pain. Re-evaluation of the ECG during complete AV block revealed subtle ST-segment elevation in the inferior leads and repeat TTE demonstrated RV dilation and hypokinesia involving the RV free wall. Emergent coronary angiography ensued and showed severely impaired right coronary artery (RCA) perfusion, likely due to ostial obstruction. Attempts to selectively cannulate the RCA were unsuccessful, precluding stent implantation. The patient was managed conservatively, with close hemodynamic monitoring.<br /> The patient gradually improved, and on the sixth post-procedural day, multi-slice computed tomography (CT) revealed suboptimal lateral apposition of the valve prosthesis on the right side, along with hypoattenuated leaflet thickening (HALT) affecting the non-coronary cusp and restricted leaflet motion (RLM). Warfarin therapy was initiated, and the patient continued to improve. </span></span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-family:"Calibri",sans-serif">At discharge, the patient demonstrated full recovery of RV function, with resolution of all regional wall motion abnormalities.</span></span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-family:"Calibri",sans-serif">One month-follow up CT scan showed complete HALT resolution and normalization of leaflet motion, with the patient being asymptomatic.</span></span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><strong><span style="font-family:"Calibri",sans-serif">CONCLUSION: </span></strong><span style="font-family:"Calibri",sans-serif">This case underscores the complexity of post-TAVI complications and highlights the ongoing uncertainty surrounding the clinical significance and management of HALT. Although HALT is a frequent imaging finding, its relationship with adverse clinical events, such as myocardial infarction, remains poorly understood. </span></span><span style="font-family:Calibri,sans-serif">The patient’s clinical course coincided with the identification of HALT, and although a direct causal relationship cannot be definitely established, the lack of other identifiable causes reinforces the hypothesis of a potential link between the two.</span></span><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-family:"Calibri",sans-serif"> The initiation of warfarin therapy led to complete resolution of HALT, suggesting a possible benefit of anticoagulation in selected cases. However, further research is essential to clarify the impact of HALT on patient outcomes and to determine the most effective management strategies.</span></span></span></p>
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