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Observational Study
. 2021 Oct;37(10):1522-1529.
doi: 10.1016/j.cjca.2021.05.002. Epub 2021 May 14.

Catastrophic Cardiac Events During Transcatheter Aortic Valve Replacement

Yafen Liang  1 , Abhijeet Dhoble  2 , Adarsh Pakanati  3 , Yelin Zhao  2 , Felix Kork  4 , Wei Ruan  3 , Travis Markham  3 , Richard Smalling  2 , Prakash Balan  2 , Anthony Estrera  5 , Tom C Nguyen  5 , Igor Gregoric  6 , Biswajit Kar  6 , Holger Eltzschig  3
Affiliations
Observational Study

Catastrophic Cardiac Events During Transcatheter Aortic Valve Replacement

Yafen Liang et al. Can J Cardiol. 2021 Oct.

Abstract

Background: Perioperative complications of transcatheter aortic valve replacement (TAVR) are decreasing but can be catastrophic when they occur. Systematic reports of the nature of these events are lacking in the contemporary era. Our study aimed to report the incidence, outcomes, and perioperative management of catastrophic cardiac events in patients undergoing TAVR and to propose a working strategy to address these complications.

Methods: This is a retrospective cohort study of patients who developed catastrophic cardiac events during or immediately after TAVR between 2015 and 2019 at a single academic centre.

Results: Of 2102 patients who underwent TAVR, 51 (2.5%) developed catastrophic cardiac events. The causes included cardiac perforation and tamponade (n = 19, 37.3%), acute left- ventricular failure (n = 10, 19.6%), coronary artery obstruction (n = 10, 19.6%), aortic-root disruption (n = 7, 13.7%), and device embolization (n = 5, 9.8%). Twenty-four patients (47.0%) with catastrophic cardiac events required stabilization by either intra-aortic balloon counter-pulsation or extracorporeal membrane oxygenation. The in-hospital mortality rate increased by 11.7-fold for patients with catastrophic cardiac events compared with those without (25.5% vs 2.0%, P < 0.001). Patients who developed aortic root disruption had the highest mortality rate (42.8%) compared with the others. The incidence of catastrophic cardiac events remained stable over a 5-year period, but the associated mortality decreased from 38.5% in 2015 to 9.1% in 2019.

Conclusions: Catastrophic cardiac events during TAVR are rare, but they account for a dramatic increase in perioperative mortality. Early recognition and development of a standardized perioperative team approach can help manage patients experiencing these complications.

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Figures

Figure 1.
Figure 1.
Incidence of cardiac catastrophic events and associated mortality rate for the year 2015 to 2019. The figure demonstrates that the incidence of catastrophic cardiac events remained relatively stable over the 5-year study period, however, the mortality rates decreased remarkably from 38.5% in 2015 to 9.1% in 2019.
Figure 2.
Figure 2.
Complication profile changes from year 2015 to 2019 for patients undergoing transcatheter aortic valve replacement procedure. The figure demonstrates that the incidence of high mortality complications such as device embolization and annulus disruption decreased remarkably over time, while other low mortality complications such as coronary artery obstruction and ventricular failure remained relatively stable.
Figure 3.
Figure 3.
A proposed standardized algorithm for early differential diagnosis and perioperative management approaches of catastrophic cardiac events during transcatheter aortic valve replacement. This algorithm focuses on the expeditious utilization of diagnostic tools (echocardiography, angiography) and the application of mechanical circulatory support (MCS) in the temporization of patients with hemodynamic instability. AI: aortic insufficiency; CABG: coronary artery bypass graft; ECG: electrocardiogram; ICU: intensive care unit; PCI: percutaneous coronary intervention; PTCA: percutaneous transluminal coronary angioplasty.
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