A Challenging Case of Non-Occlusive Mesenteric Ischemia After Transcatheter Aortic Valve Replacement

George Michalopoulos MD; Viktoriya Bikeyeva MD; Giovanni Paolella MD; Joseph Adams DO; Andrii Labchuk MD; Nishant Patel MD; Neal Sawlani MPH MD; Adib Chaus MD

A Challenging Case of Non-Occlusive Mesenteric Ischemia After Transcatheter Aortic Valve Replacement

George Michalopoulos MD
, Viktoriya Bikeyeva MD
, Giovanni Paolella MD
, Joseph Adams DO
, Andrii Labchuk MD
, Nishant Patel MD
, Neal Sawlani MPH MD
, Adib Chaus MD

Internal Medicine, Advocate Lutheran General Hospital, Advocate Health
Advocate Aurora Health
Cardiology, Advocate Lutheran General Hospital, Advocate Health
Interventional Cardiology, Advocate Lutheran General Hospital, Advocate Health

Research output: Contribution to conference › Poster › peer-review

Abstract

Introduction/Background:

Since 2019 the volume of Transcatheter Aortic Valve Replacements (TAVR) performed annually has surpassed Surgical Aortic Valve Replacements because of its favorable outcomes and reduction in median length of hospital stay. Potential complications such as high-grade AV block, tamponade, and hemorrhage can occur with TAVR. Non-occlusive mesenteric ischemia (NOMI) is a rare complication of TAVR but carries a high mortality. Our report presents a case of NOMI resulting in extensive bowel necrosis and patient mortality.

Description:

Patient is a 79-year-old female with history of abdominal aortic aneurysm status post Endovascular Aneurysm Repair (EVAR), and stable thoracic aortic aneurysm being evaluated for recurrent heart failure exacerbations and progressive dyspnea. Transthoracic echocardiogram (TTE) demonstrated low-flow low-gradient severe aortic stenosis with ejection fraction (EF) of 45%. A SAPIEN Ultra Resilia 26 mm valve was successfully implanted, and temporary pacemaker was placed due to transient AV block. TTE post-procedure revealed improved EF of 65%. Twenty-four hours later the patient developed profuse diarrhea and severe left sided abdominal pain. Labs at that time demonstrated leukocytosis with neutrophilic predominance and lactic acidosis. CT abdomen showed extensive mesenteric and gastric pneumatosis. Emergent laparotomy was performed which revealed necrosis from the gastroesophageal junction to the distal small bowel. Given the extent of necrosis and poor prognosis, the decision was made to proceed with palliative treatment.

Discussion:

Our patient had known non-obstructive stenosis of the eliac arteries with high grade stenosis of the Superior and Inferior Mesenteric arteries. Rapid pacing during TAVR deployment likely led to subsequent mesenteric ischemia. Therefore, special attention must be paid to patients with history of endovascular interventions such as EVAR or thoracic endovascular aortic repair, particularly in regard to the pre-procedural assessment of the mesenteric vasculature. Imaging modalities such as mesenteric CTA or MRA could allow for further risk stratification and prevention of NOMI. Additionally, post-procedural monitoring of lactic acid trends and interval abdominal examinations may afford earlier detection and subsequent intervention. Further investigation is necessary to identify effective pre-procedural risk stratification methods as well as post-procedural assessments and interventions.

Original language	American English
Status	Published - May 21 2025

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A Challenging Case of Non-Occlusive Mesenteric Ischemia After Tra

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Cite this

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title = "A Challenging Case of Non-Occlusive Mesenteric Ischemia After Transcatheter Aortic Valve Replacement",

abstract = "Introduction/Background: Since 2019 the volume of Transcatheter Aortic Valve Replacements (TAVR) performed annually has surpassed Surgical Aortic Valve Replacements because of its favorable outcomes and reduction in median length of hospital stay. Potential complications such as high-grade AV block, tamponade, and hemorrhage can occur with TAVR. Non-occlusive mesenteric ischemia (NOMI) is a rare complication of TAVR but carries a high mortality. Our report presents a case of NOMI resulting in extensive bowel necrosis and patient mortality. Description: Patient is a 79-year-old female with history of abdominal aortic aneurysm status post Endovascular Aneurysm Repair (EVAR), and stable thoracic aortic aneurysm being evaluated for recurrent heart failure exacerbations and progressive dyspnea. Transthoracic echocardiogram (TTE) demonstrated low-flow low-gradient severe aortic stenosis with ejection fraction (EF) of 45\%. A SAPIEN Ultra Resilia 26 mm valve was successfully implanted, and temporary pacemaker was placed due to transient AV block. TTE post-procedure revealed improved EF of 65\%. Twenty-four hours later the patient developed profuse diarrhea and severe left sided abdominal pain. Labs at that time demonstrated leukocytosis with neutrophilic predominance and lactic acidosis. CT abdomen showed extensive mesenteric and gastric pneumatosis. Emergent laparotomy was performed which revealed necrosis from the gastroesophageal junction to the distal small bowel. Given the extent of necrosis and poor prognosis, the decision was made to proceed with palliative treatment. Discussion: Our patient had known non-obstructive stenosis of the eliac arteries with high grade stenosis of the Superior and Inferior Mesenteric arteries. Rapid pacing during TAVR deployment likely led to subsequent mesenteric ischemia. Therefore, special attention must be paid to patients with history of endovascular interventions such as EVAR or thoracic endovascular aortic repair, particularly in regard to the pre-procedural assessment of the mesenteric vasculature. Imaging modalities such as mesenteric CTA or MRA could allow for further risk stratification and prevention of NOMI. Additionally, post-procedural monitoring of lactic acid trends and interval abdominal examinations may afford earlier detection and subsequent intervention. Further investigation is necessary to identify effective pre-procedural risk stratification methods as well as post-procedural assessments and interventions.",

author = "MD, \{George Michalopoulos\} and MD, \{Viktoriya Bikeyeva\} and MD, \{Giovanni Paolella\} and DO, \{Joseph Adams\} and MD, \{Andrii Labchuk\} and MD, \{Nishant Patel\} and \{Sawlani MPH MD\}, Neal and MD, \{Adib Chaus\}",

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month = may,

day = "21",

language = "American English",

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TY - CONF

T1 - A Challenging Case of Non-Occlusive Mesenteric Ischemia After Transcatheter Aortic Valve Replacement

AU - MD, George Michalopoulos

AU - MD, Viktoriya Bikeyeva

AU - MD, Giovanni Paolella

AU - DO, Joseph Adams

AU - MD, Andrii Labchuk

AU - MD, Nishant Patel

AU - Sawlani MPH MD, Neal

AU - MD, Adib Chaus

PY - 2025/5/21

Y1 - 2025/5/21

N2 - Introduction/Background: Since 2019 the volume of Transcatheter Aortic Valve Replacements (TAVR) performed annually has surpassed Surgical Aortic Valve Replacements because of its favorable outcomes and reduction in median length of hospital stay. Potential complications such as high-grade AV block, tamponade, and hemorrhage can occur with TAVR. Non-occlusive mesenteric ischemia (NOMI) is a rare complication of TAVR but carries a high mortality. Our report presents a case of NOMI resulting in extensive bowel necrosis and patient mortality. Description: Patient is a 79-year-old female with history of abdominal aortic aneurysm status post Endovascular Aneurysm Repair (EVAR), and stable thoracic aortic aneurysm being evaluated for recurrent heart failure exacerbations and progressive dyspnea. Transthoracic echocardiogram (TTE) demonstrated low-flow low-gradient severe aortic stenosis with ejection fraction (EF) of 45%. A SAPIEN Ultra Resilia 26 mm valve was successfully implanted, and temporary pacemaker was placed due to transient AV block. TTE post-procedure revealed improved EF of 65%. Twenty-four hours later the patient developed profuse diarrhea and severe left sided abdominal pain. Labs at that time demonstrated leukocytosis with neutrophilic predominance and lactic acidosis. CT abdomen showed extensive mesenteric and gastric pneumatosis. Emergent laparotomy was performed which revealed necrosis from the gastroesophageal junction to the distal small bowel. Given the extent of necrosis and poor prognosis, the decision was made to proceed with palliative treatment. Discussion: Our patient had known non-obstructive stenosis of the eliac arteries with high grade stenosis of the Superior and Inferior Mesenteric arteries. Rapid pacing during TAVR deployment likely led to subsequent mesenteric ischemia. Therefore, special attention must be paid to patients with history of endovascular interventions such as EVAR or thoracic endovascular aortic repair, particularly in regard to the pre-procedural assessment of the mesenteric vasculature. Imaging modalities such as mesenteric CTA or MRA could allow for further risk stratification and prevention of NOMI. Additionally, post-procedural monitoring of lactic acid trends and interval abdominal examinations may afford earlier detection and subsequent intervention. Further investigation is necessary to identify effective pre-procedural risk stratification methods as well as post-procedural assessments and interventions.

AB - Introduction/Background: Since 2019 the volume of Transcatheter Aortic Valve Replacements (TAVR) performed annually has surpassed Surgical Aortic Valve Replacements because of its favorable outcomes and reduction in median length of hospital stay. Potential complications such as high-grade AV block, tamponade, and hemorrhage can occur with TAVR. Non-occlusive mesenteric ischemia (NOMI) is a rare complication of TAVR but carries a high mortality. Our report presents a case of NOMI resulting in extensive bowel necrosis and patient mortality. Description: Patient is a 79-year-old female with history of abdominal aortic aneurysm status post Endovascular Aneurysm Repair (EVAR), and stable thoracic aortic aneurysm being evaluated for recurrent heart failure exacerbations and progressive dyspnea. Transthoracic echocardiogram (TTE) demonstrated low-flow low-gradient severe aortic stenosis with ejection fraction (EF) of 45%. A SAPIEN Ultra Resilia 26 mm valve was successfully implanted, and temporary pacemaker was placed due to transient AV block. TTE post-procedure revealed improved EF of 65%. Twenty-four hours later the patient developed profuse diarrhea and severe left sided abdominal pain. Labs at that time demonstrated leukocytosis with neutrophilic predominance and lactic acidosis. CT abdomen showed extensive mesenteric and gastric pneumatosis. Emergent laparotomy was performed which revealed necrosis from the gastroesophageal junction to the distal small bowel. Given the extent of necrosis and poor prognosis, the decision was made to proceed with palliative treatment. Discussion: Our patient had known non-obstructive stenosis of the eliac arteries with high grade stenosis of the Superior and Inferior Mesenteric arteries. Rapid pacing during TAVR deployment likely led to subsequent mesenteric ischemia. Therefore, special attention must be paid to patients with history of endovascular interventions such as EVAR or thoracic endovascular aortic repair, particularly in regard to the pre-procedural assessment of the mesenteric vasculature. Imaging modalities such as mesenteric CTA or MRA could allow for further risk stratification and prevention of NOMI. Additionally, post-procedural monitoring of lactic acid trends and interval abdominal examinations may afford earlier detection and subsequent intervention. Further investigation is necessary to identify effective pre-procedural risk stratification methods as well as post-procedural assessments and interventions.

M3 - Poster

ER -