Protamine-Exacerbated Right Ventricular Failure After TAVR in Critical Aortic Stenosis.

BACKGROUND

Protamine is routinely administered for heparin reversal after transcatheter aortic valve replacement (TAVR), but protamine reaction is an under-recognized and potentially catastrophic complication.

CASE SUMMARY: A 79-year-old man with critical aortic stenosis, baseline severe right ventricular (RV) dysfunction, and 2-vessel coronary artery disease underwent TAVR. Immediately following protamine administration for heparin reversal, he developed abrupt hemodynamic collapse with acute RV pressure overload on echocardiography requiring cardiopulmonary resuscitation. Despite inhaled nitric oxide, inotropes, and intra-aortic balloon pump, he remained hypotensive. Insertion of Impella RP resulted in immediate improvement in hemodynamics, with drop in central venous pressure from 31 to 20 mm Hg and improvement in oxygenation and RV contractility.

DISCUSSION: Early initiation of RV support with Impella RP should be considered in patients with acute RV failure secondary to protamine reaction.

TAKE-HOME MESSAGE: Patients with preexisting RV dysfunction may be susceptible to catastrophic type III protamine reaction because of limited physiologic reserve.