Valve-Related Complications in TAVI Leading to Emergent Cardiac Surgery

Transcatheter aortic valve implantation (TAVI) is now a standard procedure for the treatment of symptomatic aortic valve stenosis in many patients. In Germany, according to the annual reports from the German Institute for Quality Assurance and Transparency in Healthcare (Institut für Qualitätssicherung und Transparenz im Gesundheitswesen), the rate of serious intraprocedural complications, such as valve malpositioning or embolization, coronary obstruction, aortic dissection, annular rupture, pericardial tamponade, or severe aortic regurgitation requiring emergency cardiac surgery has decreased markedly in recent years from more than 5.5% in 2012 to 2.0% in 2019. However, with increased use, the total number of adverse events remains about 500 per year, about 100 of which require conversion to sternotomy. These, sometimes, fatal events can occur at any time and are still challenging. Therefore, the interdisciplinary TAVI heart team should be prepared and aware of possible rescue strategies.

Transcatheter aortic valve implantation in severe calcified annulus using the Lotus valve system: Increased incidence of fatal major vascular complications

OBJECTIVES

This study reports the outcome of a highly selected transcatheter aortic valve implantation (TAVI) population.

BACKGROUND

In patients with aortic valve stenosis and severe calcification of the left ventricular outflow tract and/or the annulus, the Boston Scientific Lotus valve provided a low paravalvular leakage rate omitting the risk of annular rupture.

METHODS

Until now more than 3,600 TAVI procedures were performed at our institution. Between 8/2015 and 2/2017, 634 TAVI procedures were performed, of which 80 TAVI patients with severe calcifications consecutively received the Lotus valve. Valve Academic Research Consortium (VARC)-2 criteria of these procedures were prospectively documented in our institutional TAVI registry. One year follow-up for the Lotus treated patients was completed.

RESULTS

Mean age was 82.0 ± 5.5 years. Device success was 95.0%. Conversion was required in two cases (2.5%). New permanent pacemaker implantation rate was 33.3%. Vascular complications occurred more frequent in comparison to non-Lotus treated patients (13.8 vs. 8.1%; p < .05): five minor and six major vascular complications (6.3 and 7.5%), including four fatal aortic injuries (three acute aortic dissections type A, one rupture of the aortic arch). Seventy-two-hour and 30-day mortality rates were also higher in Lotus patients (6.3 and 12.5% vs. 0.3 and 2.5%; each p < .05). One-year mortality in Lotus patients was 22.5%.

CONCLUSIONS

In TAVI procedures with the Lotus valve occurrence of vascular complications including lethal aortic injuries and mortality rates were considerably high. Furthermore, in every TAVI procedure careful examination of the aorta should be mandatory and be a part of planning it.