A Dilemma in the Extremely Low-Placed Venus A-Valve in a Cardiogenic Shock Patient

Transcatheter aortic valve replacement (TAVR) is regarded as an alternative to balloon aortic valvuloplasty in patients with severe aortic valve stenosis in cardiogenic shock. A low implantation of transcatheter heart valve (THV) can result in "supraskirt" paravalvular aortic regurgitation (PAR) and prosthesis-patient mismatch (P-PM), causing a dilemma in such a setting. A 64-year-old man presented to our emergency department with severe aortic stenosis and acute heart failure causing cardiogenic shock. An urgent transfemoral TAVR was performed under general anesthesia in a hybrid room. Predilatation was performed with a 22-mm compliant balloon, and a 26-mm Venus A-Valve (Venus MedTech, Hangzhou, China) was deployed. After valve implantation, the hemodynamic conditions of the patient rapidly deteriorated; therefore, cardiopulmonary resuscitation and extracorporeal circulation support were initiated. Aortography and transthoracic echocardiography (TEE) illustrated an extremely low implantation of THV, with moderate to severe supraskirt PAR and moderate P-PM. After evaluation of the hemodynamic tolerability of PAR, a median sternotomy was done, and surgery was performed. The patient died due to severe sepsis and hyperkalemia 14 days after the procedure. The management of urgent TAVR in cardiogenic shock should be revised and reexamined. A widespread and practical percutaneous technique to manage implant failure of THV is required to avoid surgical bailout.