Outcomes of Emergency Transcatheter Aortic Valve Replacement

Abstract

Objective To identify outcomes of patients undergoing emergency transcatheter aortic valve replacement (TAVR) and determine predictors of in-hospital mortality. Background Emergency TAVR has emerged as a viable treatment strategy for patients with decompensated severe aortic stenosis and/or regurgitation; however, data on patients undergoing emergency TAVR are limited. Methods All emergency TAVR procedures were identified from a single tertiary academic center between January 2015 and August 2018. Results 31 patients underwent emergency TAVR due to cardiogenic shock (26 patients), electrical instability with incessant ventricular tachycardia (2 patients), severe refractory angina (2 patients), and decompensated heart failure with hypoxemic respiratory failure requiring mechanical ventilation (1 patient). Mechanical circulatory support (MCS) was used in 16 (51.6%). MCS initiation occurred immediately prior to TAVR in 10 patients and placed post-TAVR in 6 patients. 6 patients died before hospital discharge (in-hospital mortality 19.4%). 1-year and 2-year survival rates were 61.0% and 55.9%, respectively. Univariate predictors of in-hospital mortality were preprocedural pulmonary artery pulsatility index (PAPi) ≤1.8 (66.7% vs. 20.0%, p=0.01), intraprocedural cardiopulmonary resuscitation (CPR) (83.3% vs 4.0%, p ≤ 0.001), acute kidney injury post-TAVR (80.0% vs. 4.2%, p ≤ 0.001), initiation of dialysis post-TAVR (60.0% vs. 4.2%, p ≤ 0.001), and MCS initiation post-TAVR (50.0% vs. 12.0%, p=0.03). MCS initiation before TAVR was associated with improved survival compared with post-TAVR initiation. Conclusion Emergency TAVR in extreme risk patients with acute decompensated heart failure or cardiogenic shock secondary to severe aortic valve disease is associated with high in-hospital mortality rates. Careful patient selection taking into account right heart function, assessed by PAPi, and early utilization of MCS may improve survival following emergency TAVR.

Efficacy and Safety of Emergent Transcatheter Aortic Valve Implantation in Patients with Acute Decompensated Aortic Stenosis: Systematic Review and Meta-Analysis

“…Antithrombotic regimens, commonly administered to patients with atrial fibrillation, might be a crucial cause of the increased bleeding after TAVI [ 29 ]. Actually, a large proportion of patients required mechanical circulatory support and/or mechanical ventilation at the time of TAVI [ 30 ], which complicated the use of antithrombotic agents and increased the occurrence rate of bleeding.…”

Outcomes of urgent/emergent transcatheter mitral valve repair (MitraClip): A single center experience

“…AKI has previously been associated with increased short‐ and long‐term mortality following TMVr, suggesting that identifying patients at risk of AKI and providing appropriate periprocedural hemodynamic monitoring and support is likely to enhance outcomes 33,34 . Small studies of MCS use in patients undergoing transcatheter aortic valve replacement have suggested that elective as compared to emergent or “bail‐out” MCS utilization may improve survival 35,36 . Rizik et al described three cases of CS complicated by severe MR that were successfully treated with MCS and TMVr but the potential impact of MCS use on the likelihood of postprocedural survival in this population remains an open question amenable to further study 37 .…”

The Role of Antegrade Balloon Aortic Valvuloplasty in a Patient with Low-flow, Low-gradient Aortic Stenosis and ST-elevation Myocardial Infarction

“…A 14-Fr sheath was placed in the right femoral vein, and the left atrium was accessed with an 8-Fr with symptomatic LFLG-AS, STEMI, and progressive acute heart failure. Emergent TAVR is the most feasible life-saving treatment ; however, further studies are needed to defi ne the role of this procedure [2][3][4] .…”