Cengiz , Turgay , Ali Osman , Mustafa , Sevket , Ugur , Ahmet , Adem , Mehmet Ali , and Atila: Severe Gastrointestinal Bleeding Due to Angiodysplasia after Transcatheter Aortic Valve Implantation in a Patient with High Frailty; What about Antiplatelet and Anticoagulant Therapy?.

Dear Editor,

Severe aortic stenosis is associated with significant morbidity and mortality if untreated. The transcatheter aortic valve implantation(TAVI) is now feasable and effective gold standart treatment option in patients with severe aortic valve stenosis (AS) and associated with similar rate of major adverse events compared to the surgery [1-8]. The relation between aortic stenosis and gastrointestinal angiodysplasia was known as Heyde’s Syndrome since 1958. High fluid shear stress through the narrowed valve is thought to be the underlying mechanism leads to the mechanical disruption of the large von Willebrand factor multimers. Aortic valve replacement either surgical or with TAVI seems to reduce gastrointestinal bleeding in approximately 80% in patients with Heyde syndrome in whom gastrointestinal bleeding is associated with intestinal angiodysplasia due to acquired von Willebrand’s disease (type 2A) and aortic valve stenosis. The patients especially with atrial fibrillation who need anticoagulant therapy may have bleeding risk despite aortic valve replacement [9-20]. We report a case of patient presenting with a massive intestinal bleeding originating from intestinal angiodysplasia after percutaneous aortic valve replacement.

Herein, we report a case of a 76-year-old man with massive gastrointestinal bleeding after successful TAVI procedure due to the triple therapy(acetylsalicylic acid-100 mg, clopidogrel-75 mg and apixaban - 2x2.5 mg). The patient was admitted to our hospital because of severe and symptomatic coronary artery [left anterior descending artery(LAD)] and aortic valve stenosis. The patient had also hypertension, diabetes, chronic atrial fibrillation, dyspnea(functional class II-III) and syncope on his medical history. On physical examination, the arterial blood pressure was 110/70 mm Hg, the pulse was 76 bpm and irregular. There was a 3/6 systolic murmur on the right sternal border radiating to the right side of the neck. The peripheral arterial pulses were weak. There was high voltage criteria and atrial fibrillation on his surface electrocardiography. There was significant and calcific stenosis on LAD with coronary angiography and computed tomography angiography (Fig.1). On thoracic echocardiography, there were severe left ventricular hypertrophy, severe left ventricular dysfunction and global hypokinesia and left ventricular ejection fraction(LVEF) was 26%. Aortic valve was severely calcific and aortic valve area was 0,6 cm2. Aortic valve maximal/mean pressure gradient: 47/30 mm. In order to detect the severity of the aortic valve stenosis and severity of LAD stenosis, we performed dobutamine stress echocardiography and viability study. There was viable tissue in the myocardium and aortic valve mean gradient was increased to 48 mmHg. LVEF was also increased to 50%. The patient was diagnosed as left heart failure, low flow-low gradient aortic valve stenosis and LAD stenosis, so he was referred to the surgery but he was rejected because of the high calculated Euro Score II value (65%). Because of the adequate left ventricular reserve, our heart team decided to perform the TAVI procedure because of the high cardiac surgery risk and the patient’s poor clinical state. The annulus aorta diameter was measured 26 mm and femoral arterial system images were suitable for percutaneous intervention. First of all, we implanted a VVI-R pacemaker and implantable cardioverter defibrillator because of the low LVEF for primary prevention. Then one week later, after adequate balloon inflation, a 4.0x18 mm drug eluting stent was implanted to calcific lesion at the mid segment of the LAD (Fig.2). After 6 months, the patient was still symptomatic and had low LVEF and low gradient.

Figure 1.

CT angiographic window of the aortic stenosis before TAVI

icfj.2016.8.108-g001.jpg

After local anesthesia of the bilateral femoral regions, left femoral artery was used for aortography and right femoral artery was used TAVI procedure. The aortography was performed with a pigtail catheter to set the optimal landing zone of the valve with anteroposterior and left anterior oblique and cranial projection. A temporary pacemaker lead was inserted to the right ventricular apex for rapid pacing to obtain lower blood pressure during procedure. Then, a hydrophilic guiding wire was advanced to the left ventricle via left Amplatz guiding catheter. Previously adjusted balloon under rapid pacing was inflated at the level of the aortic valve. After balloon-pre-dilatation, a 26 mm Edwards Sapien XT valve was implanted (Fig. 3). Transthoracic echocardiography was also performed to control the valve. After that, the last final aortography was done to detect any complication. The procedure was finished succesfully with no complication and the patient was discharged with acetylsalicylic acid-100 mg, clopidogrel-75 mg and apixaban-2x2.5 mg at 7 days after procedure.

We have to start tripple therapy because of the risks of stroke and valve thrombosis. When the patient was using this therapy, he was admitted to the hospital because of severe gastointestinal bleeding and he suffered severe recurrent blood loss from intestinal angiodysplasia two months later the TAVI procedure. There are some solutions to stop the bleeding but localization of the culprit lesion in patients with angiodysplasia during bleeding is usually difficult. Intestinal surgical resection may not solve the problem as first line therapy without AVR due to recurrent bleeding from other segments of the gastrointestinal tract. Unfortunately, the patient was died.

Figure 2.

Angiographic windows of the stent implantation to the LAD and VVI-ICD

icfj.2016.8.108-g002.jpg

Figure 3.

The images of the valve implantation

icfj.2016.8.108-g003.jpg

In conclusion, we recommend close monitoring and take attention for the patients with aortic valve replacement with TAVI who had prior intestinal angiodysplasia presenting with Heyde’s syndrome. We advice that anticoagulants and antiaggregants must be administered carefully in patients with high bleeding and thrombosis risk in order to minimize the risk of further bleeding as in our case.

Declarations of Interest

The authors declare no conflicts of interest.

Acknowledgements

The authors state that they abide by the “Requirements for Ethical Publishing in Biomedical Journals” [21].

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Copyright (c) 2016 cengiz ozturk, turgay celik, ali osman yildirim, Mustafa Demir, sevket balta, ugur bozlar, ahmet ozturk, adem guler, mehmet ali sahin, atila iyisoy

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