A 84-year-old woman was referred for transcatheter aortic valve replacement. Computed tomography showed an annular area of 429 mm², with a focal calcified annular nodule. Therefore, transfemoral implantation of a 23 mm Sapien S3 valve (Edwards, Irvine, CA, USA) was planned (the recommended annular area for 23 mm valve is 338–430 mm²). Post valve deployment, a mild–moderate paravalvular leak was seen, and the valve was therefore post-dilated with an additional 1 cc of diluted contrast, ameliorating the leak (see Supplementary material online, Video S1). Following percutaneous access closure, the patient developed sudden hypotension due to cardiac tamponade. Emergent pericardiocentesis retrieved 1 L of bloody effusion. Aortic root angiogram, performed via right radial access, revealed an annular rupture with active bleeding into the pericardium (Panel A, see Supplementary material online, Video S2). Over the next 10 min, 2.5 L of blood was aspirated prompting further intervention. A 6 Fr 90 cm shuttle sheath (Cook, Bloomington, IN, USA) was advanced into the root and the perforation was accessed with a 5 Fr Amplatz left-I catheter and a 0.035″ angled stiff Glide wire (Terumo, Tokyo, Japan). Attempts to deliver 6 and 5 Fr shuttle sheaths were unsuccessful due to sheath halting by the valve struts. Therefore, sequential delivery of the largest two readily available (6 mm) Amplatzer Vascular Plug-IV (Abbott Vascular, Saint Paul, MN, USA) was performed via a 5 Fr Judkins right catheter (Panels B–F, see Supplementary material online, Video S3). During plug delivery (∼25 min), additional 3.5 L of effusion were aspirated. After plug delivery, the annular bleeding decreased significantly and a total of 800 cc of blood was retrieved over the next 24 h. The patient was discharged home on Day 7. Computed tomography and echocardiography at 30 days showed stable plug position and normal transcatheter valve function (Panels G–I, see Supplementary material online, Video S4). (Panel A) Aortic root angiogram showing annular disruption and active bleeding into the pericardium (red arrows). Asterisks indicate the percutaneous drainage catheter. (Panel B) Amplatz left-1 diagnostic catheter engaging the perforation. (Panel C) Safety 0.018″ V-18 wire kept in the pericardium to maintain access during catheter exchanges (double arrows). (Panels D and E) After delivering the first AVP-4 plug, the 90 cm shuttle sheath (triple arrows) was brought close to the perforation. The safety wire was then used to advance a 5 Fr Judkins-4 catheter into the pericardium for a 2nd plug delivery. (Panel F) Final image after releasing of the two AVP-4 plugs. (Panel G) A modified long-axis view showing the two AVP-4 plugs (yellow arrows) near the right coronary artery (double asterisks). (Panel H) A modified short-axis axial view of the aortic annulus showing the two plugs, with the proximal part of one plug protruding inside the valve stent. ^†Indicates the left main coronary artery. (Panel I) A modified three chamber view illustrating the plugs in the aortic annulus at the level of the right ventricular outflow tract. AVP-4, Amplatzer vascular plug-4; AO, aorta; PA, pulmonary artery; LA, left atrium; LV, left ventricle.

中文翻译：

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经导管主动脉瓣置换术中的环形破裂：用安培创血管塞治疗

一名84岁的妇女因经导管主动脉瓣置换术而被转诊。计算机体层摄影术显示一个429 mm ²的环形区域，具有局灶性钙化的环形结节。因此，已计划经股骨植入23 mm Sapien S3瓣膜（爱德华兹，欧文，加利福尼亚州，美国）（推荐的23 mm瓣膜环形面积为338–430 mm ²）。瓣膜展开后，观察到轻度至中度瓣周漏，因此瓣膜再用1 cc稀释造影剂进行后扩张，从而减轻了渗漏（请参见在线补充材料，视频S1）。经皮通路封闭后，患者因心脏压塞而突然发生低血压。紧急的心包穿刺术取出了1 L的血性积液。通过右radial骨入路进行的主动脉根血管造影显示环形破裂，并有活跃的出血渗入心包膜（图A，请参见在线补充材料，视频S2））。在接下来的10分钟内，抽吸了2.5 L血液，促使进一步干预。将一条6 Fr的90 cm穿梭护套（Cook，Bloomington，印第安纳州，美国）推入根部，并用5 Fr Amplatz left-I导管和0.035英寸成角度的刚性滑线（Terumo，东京，日本）进入穿孔。 。由于气门撑杆停止了鞘管的输送，因此未能成功输送6和5 Fr梭形鞘管。因此，通过5 Fr Judkins右导管（图B – F，参见在线补充材料，影片S3）。在塞子输送过程中（约25分钟），吸出了另外3.5 L的积液。输送栓塞后，环形出血明显减少，并且在接下来的24小时内回收了总共800 cc的血液。患者在第7天出院回家。计算机断层扫描和超声心动图在30天时显示稳定的栓塞位置和正常的经导管瓣膜功能（面板G–I，请参见在线补充材料，视频S4）。（A组）主动脉根血管造影显示环形破裂和活动性出血进入心包（红色箭头）。星号表示经皮引流导管。（B板）Amplatz左1诊断导管接合穿孔。（C板）安全性0.018英寸V-18导线保留在心包内，以在更换导管时保持接触（双箭头）。（D和E面板）交付第一个AVP-4插头后，将90厘米的穿梭护套（三重箭头）靠近孔眼。然后使用安全线将5 Fr Judkins-4导管推进到心包中，以进行第二次栓塞递送。（图F）释放两个AVP-4插头后的最终图像。（G组）修改后的长轴视图，显示了右冠状动脉附近的两个AVP-4塞子（黄色箭头）（双星号）。（H组）主动脉瓣环的修改后的短轴轴向视图，显示了两个塞子，一个塞子的近端突出到了瓣膜支架内部。^†表示左主冠状动脉。（第I幅）修改后的三腔视图，显示了右心室流出道水平处主动脉瓣环中的栓塞。AVP-4，Amplatzer血管栓塞4; AO，主动脉；PA，肺动脉；洛杉矶，左心房；LV，左心室。