Post trans-catheter aortic valve replacement shock: Back to the basics

Transcatheter aortic valve replacement (TAVR) is indicated for the treatment of patients with severe aortic stenosis (AS) at low, intermediate, and high risk. Immediate complications post-TAVR that lead to hemodynamic compromise include: retroperitoneal bleeding, aortic dissection or rupture, pericardial tamponade, coronary ostial obstruction, acute severe central or paravalvular regurgitation, heart block, and suicide left ventricle. The presence of significant paravalvular leak (PVL) after TAVR is now an uncommon complication with newer generation devices. We present a case of an 82-year-old frail female patient who presented to our clinic with dyspnea upon minimal exertion and orthopnea. She was found to have severe AS that was treated with TAVR. The procedure was complicated by hemodynamic compromise due to severe PVL and left ventricular outflow tract (LVOT) obstruction which was underestimated by transthoracic echocardiography. The PVL was eventually treated with a vascular plug device and the LVOT obstruction was treated with alcohol septal ablation. This case highlights the vital role of early and aggressive work up in unstable patients post-TAVR and the importance of transesophageal echocardiography in patients with unexplained hypotension post-TAVR to unmask the severe PVL and dynamic LVOT obstruction. <Learning objective: Early and aggressive work-up is necessary in unstable patients post-transcatheter aortic valve replacement. Anesthesia is needed in high-risk cases to quickly deal with hemodynamic changes. Transesophageal echocardiography is particularly required when a patient develops unexplained hypotension as it can unmask severe paravalvular leak and dynamic left ventricular outflow obstruction.>.