Severe intraprocedural complications after transcatheter aortic valve implantation: calling for a heart team approach

TY - JOUR

T1 - Severe intraprocedural complications after transcatheter aortic valve implantation: calling for a heart team approach

AU - Seiffert, Moritz

AU - Conradi, Lenard

AU - Baldus, Stephan

AU - Schirmer, Johannes

AU - Blankenberg, Stefan

AU - Reichenspurner, Hermann

AU - Diemert, Patrick

AU - Treede, Hendrik

PY - 2013/9

Y1 - 2013/9

N2 - OBJECTIVES: Transcatheter aortic valve implantation (TAVI) has emerged rapidly. Despite unanimous recommendations and potentially fatal intraoperative complications, the heart-team approach is not comprehensively adopted by all centres. We sought to characterize severe intraprocedural complications during TAVI requiring immediate surgical or interventional bailout manoeuvres and evaluate outcomes.METHODS: TAVI was performed in 458 consecutive patients using a balloon-expandable or self-expanding valve through transfemoral and transapical approaches. Severe intraprocedural complications requiring intraoperative bailout manoeuvres were analysed according to the Valve Academic Research Consortium (VARC) criteria.RESULTS: Thirty-five of 458 patients (7.6%) experienced 40 major intraprocedural complications during TAVI, 13 (2.8%) requiring emergent conversion to surgery. Complications included valve embolization/migration (17%), severe aortic regurgitation (12%) and root rupture (5%), requiring immediate implantation of a second valve or conversion to surgical valve replacement. Sternotomy and surgical haemostasis were performed in 5 patients (13%) with left ventricular wire perforation and subsequent cardiac tamponade. Coronary obstruction (15%) required emergent percutaneous coronary intervention in 6 patients. At 30 days, all-cause mortality was 31.4% in patients with intraprocedural complications and 38.5% in patients requiring surgical conversion. However, mid-term survival after 30 days and exercise tolerance in surviving patients were comparable with patients undergoing uncomplicated TAVI.CONCLUSIONS: An interdisciplinary approach to TAVI facilitated bailout procedures accomplishing acceptable outcomes, despite severe intraprocedural complications. These bailout manoeuvres in potentially fatal complications were only accomplished through an interdisciplinary heart-team effort, creating a surgical and interventional safety net, which should be established in all centres performing TAVI procedures.

AB - OBJECTIVES: Transcatheter aortic valve implantation (TAVI) has emerged rapidly. Despite unanimous recommendations and potentially fatal intraoperative complications, the heart-team approach is not comprehensively adopted by all centres. We sought to characterize severe intraprocedural complications during TAVI requiring immediate surgical or interventional bailout manoeuvres and evaluate outcomes.METHODS: TAVI was performed in 458 consecutive patients using a balloon-expandable or self-expanding valve through transfemoral and transapical approaches. Severe intraprocedural complications requiring intraoperative bailout manoeuvres were analysed according to the Valve Academic Research Consortium (VARC) criteria.RESULTS: Thirty-five of 458 patients (7.6%) experienced 40 major intraprocedural complications during TAVI, 13 (2.8%) requiring emergent conversion to surgery. Complications included valve embolization/migration (17%), severe aortic regurgitation (12%) and root rupture (5%), requiring immediate implantation of a second valve or conversion to surgical valve replacement. Sternotomy and surgical haemostasis were performed in 5 patients (13%) with left ventricular wire perforation and subsequent cardiac tamponade. Coronary obstruction (15%) required emergent percutaneous coronary intervention in 6 patients. At 30 days, all-cause mortality was 31.4% in patients with intraprocedural complications and 38.5% in patients requiring surgical conversion. However, mid-term survival after 30 days and exercise tolerance in surviving patients were comparable with patients undergoing uncomplicated TAVI.CONCLUSIONS: An interdisciplinary approach to TAVI facilitated bailout procedures accomplishing acceptable outcomes, despite severe intraprocedural complications. These bailout manoeuvres in potentially fatal complications were only accomplished through an interdisciplinary heart-team effort, creating a surgical and interventional safety net, which should be established in all centres performing TAVI procedures.

KW - Aged

KW - Aged, 80 and over

KW - Female

KW - Heart Valve Prosthesis Implantation/adverse effects

KW - Humans

KW - Intraoperative Complications/etiology

KW - Kaplan-Meier Estimate

KW - Male

KW - Postoperative Complications/etiology

KW - Treatment Outcome

U2 - 10.1093/ejcts/ezt032

DO - 10.1093/ejcts/ezt032

M3 - SCORING: Journal article

C2 - 23389474

VL - 44

SP - 478

EP - 484

JO - EUR J CARDIO-THORAC

JF - EUR J CARDIO-THORAC

SN - 1010-7940

IS - 3

ER -