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      Efficacy of intraoperative transesophageal echocardiography in a case of protamine shock during transcatheter aortic valve implantation

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          Abstract

          Here, we report the case of a patient who developed protamine shock during a transcatheter aortic valve implant (TAVI) procedure, which was diagnosed by intraoperative transesophageal echocardiography (TEE). A 77-year-old man with symptomatic severe aortic stenosis and reduced left ventricular (LV) function underwent TAVI under general anesthesia. During the procedure, a transcatheter heart valve (THV) was deployed via the transfemoral approach, without any other major complications. The entire device system was then removed, and protamine sulfate was administered intravenously in 2 min.

          Two minutes after the protamine administration, severe hypotension occurred. TEE did not reveal THV malfunction or any other major complications. However, comparison of the TEE image obtained before protamine administration and that obtained 2 min after protamine administration showed right ventricular (RV) dilatation, RV free wall motion abnormality, and LV volume reduction, without any electrocardiographic changes. We diagnosed this as protamine shock and bolus infusions of phenylephrine and norepinephrine were administered, and chest compressions were initiated immediately. After 1 min, hypotension as well as the right and left ventricular size and dysfunction immediately reverted to baseline. The severe systemic hypotension resolved as well. Thereafter, he recovered from anesthesia without other complications.

          This case showed the clinical features of protamine shock with acute pulmonary hypertension. The TEE images, in this case, should be a reminder for all doctors who perform intraoperative TEE for patient monitoring when they perform procedures to treat structural heart diseases.

          Electronic supplementary material

          The online version of this article (doi:10.1186/s40981-016-0053-6) contains supplementary material, which is available to authorized users.

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          Most cited references 9

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          Transcatheter aortic valve replacement in Europe: adoption trends and factors influencing device utilization.

          The authors sought to examine the adoption of transcatheter aortic valve replacement (TAVR) in Western Europe and investigate factors that may influence the heterogeneous use of this therapy.
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            Antithrombotic treatment in transcatheter aortic valve implantation: insights for cerebrovascular and bleeding events.

            Transcatheter aortic valve implantation (TAVI) has emerged as a therapeutic alternative for patients with symptomatic aortic stenosis at high or prohibitive surgical risk. However, patients undergoing TAVI are also at high risk for both bleeding and stroke complications, and specific mechanical aspects of the procedure itself can increase the risk of these complications. The mechanisms of periprocedural bleeding complications seem to relate mainly to vascular/access site complications (related to the use of large catheters in a very old and frail elderly population), whereas the pathophysiology of cerebrovascular events remains largely unknown. Further, although mechanical complications, especially the interaction between the valve prosthesis and the native aortic valve, may play a major role in events that occur during TAVI, post-procedural events might also be related to a prothrombotic environment or state generated by the implanted valve, the occurrence of atrial arrhythmias, and associated comorbidities. Antithrombotic therapy in the setting of TAVI has been empirically determined, and unfractionated heparin during the procedure followed by dual antiplatelet therapy with aspirin (indefinitely) and clopidogrel (1 to 6 months) is the most commonly recommended treatment. However, bleeding and cerebrovascular events are common; these may be modifiable with optimization of periprocedural and post-procedural pharmacology. Further, as the field of antiplatelet and anticoagulant therapy evolves, potential drug combinations will multiply, introducing variability in treatment. Randomized trials are the best path forward to determine the balance between the efficacy and risks of antithrombotic treatment in this high risk-population.
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              Complications of transcatheter aortic valve implantation (TAVI): how to avoid and treat them

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                Author and article information

                Contributors
                +81-3-3964-1211 (30418) , kataoaki@sd5.so-net.ne.jp
                yusuke0831@gmail.com
                sekishu627@yahoo.co.jp
                a7x_mia@me.com
                hhioki@shinshu-u.ac.jp
                h.kyono@gmail.com
                sawamura@med.teikyo-u.ac.jp
                PXE00364@nifty.com
                Journal
                JA Clin Rep
                JA Clin Rep
                Ja Clinical Reports
                Springer Berlin Heidelberg (Berlin/Heidelberg )
                2363-9024
                10 October 2016
                10 October 2016
                2016
                : 2
                : 1
                Affiliations
                [1 ]Department of Medicine, Division of Cardiology, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8606 Japan
                [2 ]Department of Anesthesia, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8606 Japan
                53
                10.1186/s40981-016-0053-6
                5815465
                © The Author(s) 2016

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

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                Case Report
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                © The Author(s) 2016

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