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

Abstract

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. © The Author 2013. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.