Emergent transcatheter aortic valve implantation combined with enterectomy for acute decompensated heart failure caused by severe aortic stenosis and strangulated femoral hernia

A 74-year-old female was admitted to our department with orthopnea, oliguria, and vomiting. She had a pacemaker implanted two years ago. Physical examination revealed an 8 cm × 6 cm bulge in the right groin. The transthoracic echocardiography showed that the area of aortic orifice was 0.4 cm2 and the left ventricle ejection fraction (LVEF) was 25%. The Society of Thoracic Surgeons score was 25.6%. Abdominal ultrasound demonstrated right femoral hernia with intestinal obstruction. Because of hemodynamic instability and the risk of intestinal necrosis, emergent transcatheter aortic valve implantation (TAVI) combined with hernia repair was scheduled to perform. The procedure was performed under general anesthesia with intubation. The transesophageal echocardiography (TEE) showed that the maximal and mean pressure gradient was 64 and 35 mmHg, respectively (Panels A–C); coronary angiography indicated no coronary artery stenosis. We chose left femoral artery access for TAVI through a totally percutaneous approach. According to TEE, aortic root angiography and based on the balloon pre-dilation (Panel D), 26 Venus-A self-expandable valve was successfully implanted (Panel F). And then, the right oblique cutdown was performed, and a tense hernial sac was revealed, in which we observed an 8-cm-long necrotic bowel (Panel E). The gastrointestinal surgeon had to resect the strangulated and anastomose the normal bowel. TEE showed that the maximal and mean aortic pressure gradient was 13 and 7 mmHg, respectively (Panels G and H). Thirteen days later after the operation, the patient was discharged from the hospital with no complications. Follow-up echocardiography demonstrated that the device position was appropriate, no perivalvular leakage, and the LVEF increased to 50%.