Complications after Transfemoral Transcatheter Aortic Valve Replacement with a Balloon‐Expandable Prosthesis: The Importance of Preventative Measures and Contingency Planning

Abstract

Transcatheter aortic valve replacement (TAVR) with balloon-expandable Edwards-SAPIEN valve was superior to standard therapy in inoperable patients and noninferior to surgical aortic valve replacement in high surgical-risk, but operable patients, with severe symptomatic aortic stenosis in the randomized controlled PARTNER trial. Since the first case of TAVR with a balloon-expandable valve in 2002, several groups have reported their experience with balloon-expandable valves with high-procedural success. In the United States, the balloon-expandable Edwards-SAPIEN valve is the only transcatheter heart valve approved by the FDA for commercial use. Moreover, this is only in high-risk inoperable patients. Despite increasing experience with the TAVR procedure, it can be associated with complications, which can be technically challenging, even for an experienced operator. Complications associated with TAVR include vascular complications, valve malpositioning, regurgitation, embolization, coronary compromise, conduction abnormalities, stroke/transient ischemic attack, acute kidney injury, cardiac tamponade, and hemodynamic collapse. A thorough understanding of the procedure is essential for pre-emptive planning for procedural complications and early identification and management of complications are necessary for procedural success. We hereby review our experience of transfemoral TAVR with balloon-expandable valves, offer practical tips to maximize the likelihood of procedural success, describe pre-emptive strategies to prevent peri-procedural complications and bailout measures to manage them, should they occur. © 2018 Wiley Periodicals, Inc.

Living Donor Liver Transplantation Following Transcatheter Aortic Valve Implantation for Aortic Valvular Disease

“…TAVI, by itself, is associated with significant complications that include vascular problems, valve malpositioning, regurgitation, embolization, coronary compromise, conduction abnormalities, stroke, transient ischemic attack, acute kidney injury, cardiac tamponade, and hemodynamic collapse. 15 Early identification by thoroughly looking out for these complications and timely intervention is important for successful outcomes. The systematic review by Chakos and colleagues 16 looking at long-term outcomes of TAV1 in nearly 14 000 patients from a worldwide registry showed that survival post-TAVI is significantly inferior when compared against an age-matched population, but this is not unexpected, given the significant comorbidities in this patient population.…”

Left Ventricular Outflow Tract Migration of a Balloon-Expandable Prosthesis During Transcatheter Aortic Valve Implantation

“…Embolization into the aorta can sometimes be treated by valve repositioning and deploying into the distal aorta using transcatheter techniques with good outcomes on mid-term to long-term follow-up. 5,7,11) Meanwhile, migration of prostheses into the LV can be more challenging, and in such cases, immediate conversion to surgical treatment is often required. 5,10) To the best of our knowledge, only 4 cases have been reported which could be recovered using a transcatheter approach without conversion to surgery: two cases were resolved using the transapical approach, 12,13) and the others using the transfemoral approach.…”

CoreValve Double Jeopardy

“…8,2 Treatment of embolization into the aorta has traditionally relied on repositioning the valve into the descending aorta using endovascular snares or removal via open surgery. 8,9 Other strategies have included repositioning the valve using a valvuloplasty balloon or deploying a large stent inside the embolized valve to hold the leaflets in the open position. 10 Patients with prosthesis embolization have a high risk of mortality 11 and morbidity including stroke, 7 occlusion of major arteries, 7 and aortic dissection 12 associated with manipulation of the prosthesis in the ascending aorta.…”