his medical history included 5-times percutaneous coronary stent insertions for unstable angina , chronic obstructive pulmonary disease , atrial fibrillation , and atherosclerosis obliterans . pre - procedural echocardiography showed severe aortic stenosis ( severe thickened and calcified aortic valve , aortic valve area = 0.72 cm , aortic annulus = 22 mm ) and mild to moderate aortic regurgitation , moderate tricuspid regurgitation , both atrial enlargement , and concentric left ventricular hypertrophy . however , left ventricular systolic function ( ejection fraction = 63% ) and right ventricular systolic pressure ( 28 mmhg estimated by the maximal velocity of tricuspid regurgitation ) were in normal range . the cardiologists recommended transapical tavi instead of conventional surgery because the patient was considered as the high - risk population . after placing an invasive arterial catheter through a brachial artery , a pulmonary artery catheter was placed through right internal jugular vein , and a transesophageal echocargiographic ( tee ) probe was inserted . after a left anterior mini - thoracotomy , an angiocatheter was inserted through the apex of the left ventricle . a guidewire was passed through the aortic valve and arch , and the tip was positioned in the abdominal aorta for stability . following the two times of rapid ventricular pacing ( 200 beats / min ) for 10 seconds , the balloon valvuloplasty was performed . mcg / kg / min ) was continuously infused for maintaining blood pressure and norepinephrine 5 mcg was successively injected twice prior to rvp for balloon valvuloplasty . from anesthetic induction to rapid ventricular pacing , the patient 's vital signs were well maintained ( systolic blood pressure , 90 to 144 mmhg ; diastolic blood pressure , 46 to 70 mmhg ; central venous pressure , 7 to 12 mmhg ; mean pulmonary arterial pressure , 20 to 22 mmhg ; and heart rate , 68 to 110 beats / min ) . in addition , the mean arterial pressure was also maintained at around 50 mmhg , during rapid ventricular pacing . following the balloon valvuloplasty with rapid ventricular pacing , the mean blood pressure dropped to below 40 mmhg and did not recover . at the same time , central venous and the mean pulmonary arterial pressures were raised up to 22 mmhg and 44 mmhg , respectively . emergent extracorporeal membrane oxygenation ( ecmo ) device was initiated immediately , through femoral artery and vein . a 26-mm sapien transcatheter heart valve ( edward lifesciences , irvine , ca , usa ) was deployed under the ecmo support . however , regardless of the ecmo support and supportive medical treatments , he did not recover from the state of heart failure . finally , he died from cardiogenic shock and heart failure on post - procedure day 4 . in this mortality case , we experienced an unexpected event of fatal hemodynamic collapse , which developed immediately after a rapid ventricular pacing , although the recommended anesthetic managements were applied . previously , there has been a case report that described the severity of cardiovascular compromise after a valve implantation due to the coronary arterial occlusion . however , in our case , coronary arterial blood flow was normal . generally , for tavi procedure , similar general anesthetic technique for high risk conventional aortic valve replacement is recommended . in addition , bolus administration of a vasopressor prior to , or immediately after , a rapid ventricular pacing has been suggested to maintain coronary perfusion pressure . continuous monitoring of tee is also strongly recommended , and a hybrid operating room , which is able to initiate cardiopulmonary bypass or to convert into conventional surgery , is considered as the ideal place for the tavi procedure . those recommendations were all achieved in this case . . first , transapical approach might be potentially harmful to the heart because it involves the introduction of a large catheter through the ventricular apex . an inevitable introduction of large - bore catheter during transapical tavi could cause myocardial damage , followed by arrhythmia . although an administration of a bolus vasopressor is generally advocated , the amount of vasopressor should be titrated optimally in these patients because a relatively small dose would lead to insufficient coronary perfusion during a rapid ventricular pacing , and too much would cause severe elevation in the pulmonary arterial pressure . in addition , an increase in pulmonary arterial pressure would worsen the right ventricular contractility and cardiac output . however , to our knowledge , there is no recommendation for the individual optimal dose of vasopressor during a rapid ventricular pacing essential to the tavi procedure . moreover , the " optimal " dose of vasopressor would likely be different in patients because of the individual variation . additionally , cardiac output is absent during rapid ventricular pacing . without cardiac output , it would be questionable whether it is possible to predict the appropriate amount of vasopressor for the adequate coronary perfusion , as well as to preserve the coronary flow merely by maintaining the mean arterial pressure of around 50 mmhg . in conclusion , the anesthesiologists should keep in mind that the fatal hemodynamic collapse can develop after a rapid ventricular pacing , despite the strict adherence to currently - recommended anesthetic protocols . in addition , further studies would be recommended to find the individual optimal dose of vasopressor for more successful anesthetic management of tavi procedure .
although transcatheter aortic valve implantation ( tavi ) is generally accepted as an alternative or promising treatment option for patients with decompensated cardiovascular disease in an inoperable or high - risk condition , severe hypotension and/or arrhythmia associated with rapid ventricular pacing still poses a challenge to many clinicians . this report describes a 79-year - old patient who experienced fatal hemodynamic collapse , which suddenly developed after a rapid ventricular pacing in spite of pre - administration of vasopressor . 
 the procedure and anesthesia were uneventful until the first rapid ventricular pacing was applied . 
 following rapid ventricular pacing , his cardiovascular state was severely compromised and could not be recovered . despite early initiation of extracorporeal membrane oxygenation device and supportive care , he died from heart failure on post - procedure day four .