Managing and Correcting a "Frozen" Leaflet after TAVR G. Maluenda, I. Ben-Dor, S. Goldstein, Z. Wang, P. Corso, L. Satler, R. Waksman, A. Pichard. Interventional Cardiology Washington Hospital Center

Disclosure Statement of Financial Interest I, Gabriel Maluenda DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

Clinical presentation History 89 yo male, 76 Kg, 163 cm; s/p CABG, A.Fib, presented with progressive CHF and syncope. EF 30%, NYHA class IV. BAV performed 3 month prior to TAVR. STS 15.1% Coronary angiogram Severe native 3 vessel disease. Patent SVG to OM2 and LIMA to LAD. Occluded SVG to RCA. Thoracic aorta within normal dimensions.

Stress TTE After infusion of 20 mcg of DBT: V Max: 3.4 to 4.1 to m/sec Mean gradient: 30 to 41 mm Hg EF: 30 to 35% Aortic valve area: 0.75 cm2 Annulus: 20 mm BASELINE DBT 20 mcg

Baseline Hemodynamics Mean aortic gradient: 31 mm Hg Aortic valve area: 0.6 cm2 CO: 2.9 L/min

Edwards 23 mm Sapien Valve deployment

LV/Ao pressures after deployment

Patient developed severe hypotension and massive central AR noted on TEE

Multipurpose catheter probing of implanted valve

Aortic pressure during and after catheter probing

LV/Ao pressures after AR resolved

Clinical Course AR was resolved after catheter probing with concomitant improvement on hemodynamic status Procedure was performed completely percutaneously and patient was discharge 4 days after TAVR with trivial AR on echo. All leaflets moving normally.

Teaching points Massive central AR is uncommon after TAVR, and can be related to valve dysfunction, usually due to a “frozen” leaflet Catheter probing of the “frozen” leaflet can restore normal excursion.