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

• Published in: Catheterization and cardiovascular interventions Vol. 96; no. 3; pp. E369 - E376
• Main Authors: Hodson, Robert W., Jin, Ruyun, Ring, Michael E., Gafoor, Sameer, Verburg, Shawnna, Lehr, Eric J., Spinelli, Kateri J.
• Format: Journal Article
• Language: English
• Published: Hoboken, USA John Wiley & Sons, Inc 01-09-2020; Wiley Subscription Services, Inc
• Subjects: Aged; Aged, 80 and over; Aortic valve; Aortic Valve Stenosis - diagnosis; Aortic Valve Stenosis - mortality; Aortic Valve Stenosis - surgery; Catheterization, Peripheral - adverse effects; Catheterization, Peripheral - mortality; Coronary artery; Effusion; Emergencies; emergency sternotomy; Female; Femoral Artery; Humans; Incidence; Intraoperative Complications - diagnosis; Intraoperative Complications - mortality; Intraoperative Complications - surgery; intrathoracic complication; Male; Mortality; Occlusion; Punctures; Registries; Retrospective Studies; Risk Assessment; Risk Factors; Sternotomy - adverse effects; Sternotomy - mortality; Tamponade; Thorax; Time Factors; Transcatheter aortic valve replacement; Transcatheter Aortic Valve Replacement - adverse effects; Transcatheter Aortic Valve Replacement - mortality; Treatment Outcome; United States; United States; emergency sternotomy; Transcatheter aortic valve replacement; intrathoracic complication
• DOI: 10.1002/ccd.28620
• EISSN: 1522-726X
• ISSN: 1522-1946

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.