Intrathoracic complications associated with trans‐femoral transcatheter aortic valve replacement: Implications for emergency surgical preparedness

Abstract

Background Intrathoracic complications (ITC) requiring emergency surgical intervention occur during transcatheter aortic valve replacement (TAVR). Objectives Characterize the incidence, outcomes and predictors of ITC in a large cohort of transfemoral (TF) TAVR cases over a 5 year period. Methods Retrospective registry and chart review of all nonclinical trial TF‐TAVR patients from seven centers within one hospital system from 2012–2016. ITC were defined as cardiac perforation, new or worsening pericardial effusion/tamponade, annular rupture, thoracic aortic injury, aortic valve dislodgement, and coronary artery occlusion. Procedural and 30‐day outcomes and 1‐year mortality were compared between ITC and no ITC patients. Multivariable logistic regression was used to identify predictors of ITC. Results Over the study period, 1,581 patients had TF‐TAVR and 68 ITC occurred in 46 patients (2.9%). The most common ITCs were pericardial effusion/tamponade (59%), cardiac perforation (33%), and valve dislodgement (33%). ITC rate did not decline over time (rate (95% confidence interval) for 2012 = 0% (0–8.8%), 2013 = 1.3% (0–7.2%), 2014 = 4.4% (2.2–8.0%), 2015 = 3.5% (2.0–5.6%), and 2016 = 2.4% (1.5–3.8%)). ITC patients had worse 1‐year survival (ITC: 60.7% (45.1–73.1%), no ITC: 88.7% (87.0–90.3%); p < .001). The majority of ITC patient deaths occurred within the first 30 days. Multivariable models to predict ITC were not successful. Conclusions ITC did not decline over time in our cohort. Predictors of ITC could not be identified. While these events are rare, they are associated with worse procedural outcomes and mortality. Heart teams should continue to be prepared for emergency intervention.

Interventional closure of aortomitral perforation after TAVR: A case report

“…Ventricle perforation following TAVR is a serious and in many cases lethal complication 1,2 . In this case, the perforation in the aortomitral continuity that led to a shunt between the left atrium and ventricle was likely caused by a shift of the LVOT calcification.…”

Outcomes of transcatheter versus surgical aortic valve replacement among solid organ transplant recipients

“…25 This might have contributed to the higher rates of postoperative bleeding, vascular complications and transfusion with surgery in our study. Chronic immunosuppression has been associated with higher risk for intrathoracic complications after TAVR, including pericardial effusion and cardiac tamponade 26 . Also, vascular access options might be more limited among renal transplant recipients undergoing transfemoral TAVR, with concerns of higher vascular complications when ipsilateral femoral access to the transplanted kidney.…”

Minimum requirements in emergency kits for bailout strategies in TAVR complications

“…Even though technological improvements and increased operator experience have led to a decrease in major periprocedural complications, [2][3][4][5] the need of bailout strategies to manage potentially lifethreatening complications remains. 6 Currently, there are no specific international guidelines focused on the management of the most common life-threatening TAVR complications. Nevertheless, a prompt and standardized approach to each individual type of complications along with preassembled emergency kits seem to be useful.…”