(130) Stone Heart: A Rare Complication From Annular Rupture During TAVR Deployment

Introduction: Transcatheter aortic valve replacement (TAVR) is an increasingly popular minimally invasive option for patients needing aortic valve replacement. Annular rupture is a rare but severe complication of TAVR, with an incidence ranging from 0.4% to 2.3% and accounting for 49% to 67% of the mortality associated with the procedure. Early recognition and emergent surgical repair are imperative.
Stone Heart Syndrome, a sustained contracture of the left ventricle, is a rare but significant complication occurring in 0.3% of open-heart surgery caused by ischemia.

Description: A 68-year-old female with severe aortic stenosis underwent TAVR. After deployment with good placement, the patient’s systolic blood pressure dropped by about 30 points, prompting an echocardiogram. It revealed a large pericardial effusion which drained 1.5 liters of blood.
The patient underwent emergent surgery. An aortic annular rupture at the level of the left cusp near the left main coronary artery was discovered. An intra-operative angiogram showed a hematoma compressing the left main coronary artery requiring venous graft. The TAVR was replaced by surgical valve.
Despite hemorrhage control and revascularization, persisting ischemia of the left ventricle led to Stone Heart Syndrome, preventing weaning from cardiac bypass. The patient was transferred to ICU on ECMO (extracorporeal membrane oxygenation). The patient was arousable and neurologically intact. This extremely complex case left no options other than cardiac transplant.

Discussion: Annular rupture and stone heart are both rare complications following TAVR and cardiopulmonary bypass respectively. Regrettably, this patient experienced both conditions.
In this case, left main compression by hematoma, led to Stone Heart Syndrome. The myocardial rigor has been linked to lack of ATP. In their absence, the usual inhibition by troponin-tropomyosin on interaction with actin is lost, leading to the formation of rigor complexes and subsequent contracture.
Early detection of the complication and prompt intervention ensured hemodynamic stability throughout the event. The immediate conversion to open heart surgery, availability of ECMO and dedications of the whole medical team enabled safe transfer to the cardiac transplant center.