Abstract 16020: The Illusion of Hypertrophy: Perioperative Complications of Transcatheter Aortic Valve Replacement in a Patient With Aortic Stenosis and Cardiac Amyloidosis
Background: Cardiac amyloidosis is seen in a third of patients undergoing transcatheter aortic valve replacement (TAVR) and might lead to poor outcomes in these patients.
Case: 87 year old man, with history of severe aortic stenosis (AS, mean trans-aortic gradient 37mmHg, calculated valve area 0.6cm2) and paroxysmal atrial fibrillation, presented to the cardiology clinic with symptoms of biventricular failure. He underwent TAVR with CoreValve two months ago for recurrent heart failure with preserved ejection fraction (HFpEF) exacerbations. His hospital course was complicated by post-procedure cardiac arrest, dual-chamber atrioventricular permanent pacemaker placement for complete heart block and left anterior descending artery dissection. A repeat echocardiogram revealed normal left ventricular ejection fraction, severe concentric increase in left ventricular thickness, normal trans-aortic gradients for CoreValve and moderate aortic insufficiency (Figure 1). Longitudinal ventricular strain analysis by Speckle Tracking Echocardiography revealed globally reduced strain with relative sparing of the apex (“Apical Cherry”), suggestive of cardiac amyloidosis (Figure 1). Patient refused any further investigations and decided to pursue symptomatic management for HFpEF.
Discussion: Recurrent HFpEF exacerbations, in presence of severe AS, led to diagnostic anchoring onto AS in our patient. Hypertrophy seen with AS can resemble infiltrative cardiomyopathies on echocardiogram. Concomitant presence of aTTR-amyloidosis in this patient could have led to both HFpEF exacerbations and some of the perioperative complications seen with TAVR.
Conclusions: In patients presenting with heart failure and AS, diagnostic anchoring should be avoided. In AS patients with increased left ventricular thickness and markedly reduced longitudinal strain, consideration of cardiac amyloidosis might help with perioperative risk stratification for TAVR.
Author Disclosures: M. Sardana: None. T.E. Meyer: None. G.P. Aurigemma: None.
- © 2016 by American Heart Association, Inc.