Management and Outcome of Transcatheter Aortic Valve Implantation Requiring Surgical Intervention Focusing on the Time Interval between Complication Onset and Establishing Cardiopulmonary Bypass

Infective endocarditis complicating transcatheter aortic valve implantation (TAVI-IE) is a relatively rare condition with an incidence of 0.2%–3.1% at 1 year post implant. It is frequently caused by Enterococci, Staphylococcus aureus and coagulase negative staphylococci. While the incidence currently appears to be falling, the absolute number of cases is likely to rise substantially as TAVI expands into low risk populations following the publication of the PARTNER 3 and Evolut Low Risk trials. Important risk factors for the development of TAVI-IE include a younger age at implant and significant residual aortic regurgitation. The echocardiographic diagnosis of TAVI-IE can be challenging, and the role of supplementary imaging techniques including multislice computed tomography (MSCT) and positron emission tomography (18FDG PET) is still emerging. Treatment largely parallels that of conventional prosthetic valve endocarditis (PVE), with prolonged intravenous antibiotic therapy and consideration of surgical intervention forming the cornerstones of management. The precise role and timing of cardiac surgery in TAVI-IE is yet to be defined, with a lack of clear evidence to help identify which patients should be offered surgical intervention. Minimising unnecessary healthcare interventions (both during and after TAVI) and utilising appropriate antibiotic prophylaxis may have a role in preventing TAVI-IE, but robust evidence for specific preventative strategies is lacking. Further research is required to better select patients for advanced hybrid imaging, to guide surgical management and to inform prevention in this challenging patient cohort.

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Abstract 3047: Management Of Procedural Complications Associated With Transcatheter Aortic Valve Implantation

Circulation ◽

10.1161/circ.118.suppl_18.s_807-c ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Ruediger Lange ◽

Sabine Bleiziffer ◽

Hendrik Ruge ◽

Domenico Mazzitelli ◽

Christian Schreiber ◽

...

Keyword(s):

Cardiopulmonary Bypass ◽

Aortic Valve ◽

Transcatheter Aortic Valve Implantation ◽

Pacemaker Implantation ◽

Vascular Complications ◽

Lv Function ◽

Transcatheter Aortic Valve ◽

Surgical Suture ◽

Aortic Valve Implantation ◽

Valve Implantation

Objective The transcatheter aortic valve implantation (TAVI) technology is rapidly evolving. The complications related to these procedures are different from those seen after conventional aortic valve replacement. Herein, we report our experience on the incidence and management of procedure-related complications in the first series of TAVI. Methods Between 6/2007 and 6/2008, 112 patients (n=62 female, mean age 81.3±7y, mean logistic EuroScore 25.0±15.6%) underwent TAVI through either a retrograde (n=92 transfemoral, n=3 via subclavian artery, n=1 ascending aorta) or antegrade (n=16 transapical) approach at our institution. 95 CoreValve and 17 Edwards Sapien (n=17) prostheses were implanted. Results 30-day mortality was 8.9% (n=10). Major vascular complications occurred in 19 patients (16,9%). 2 patients with iliac or femoral rupture were treated with covered stent. 14 patients with bleeding from vascular site were treated with surgical suture or prosthesis implantation. Three patients had lethal aortic root (n=2) or abdominal (n=1) aortic rupture. Cardiac tamponade occurred in 8 patients (7.1%); among these 3 were treated conservatively, 4 underwent subxyphoid puncture and one patient had thoracotomy. Valve displacement could be treated interventionally in 5 out of 6 patients, 1 patient underwent conventional surgery. In 2 patients, with extremely poor LV function, emergent institution of cardiopulmonary bypass was required during the procedure. 5 patients underwent interventional re-valving (n=2) or surgical re-replacement (n=3) due to high-grade regurgitation (n=5) or valve displacement (n=1). Pacemaker implantation due to postprocedural AV block was required in 23 patients (20.7%). Despite these complications, the overall initial procedural success was 98 % (n= 110/112). Conclusions A significant number of complications after TAVI requires surgical treatment. Therefore, TAVI procedures should be performed in a hybrid operating room which allows for immediate surgical intervention and the rapid institution of cardiopulmonary bypass if necessary.

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A Meta-Analysis Examining Differences in Short-Term Outcomes between Sutureless and Conventional Aortic Valve Prostheses

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/imi.0000000000000221 ◽

2015 ◽

Vol 10 (6) ◽

pp. 375-382 ◽

Cited By ~ 6

Author(s):

Eoghan T. Hurley ◽

Katie E. O'Sullivan ◽

Ricardo Segurado ◽

John P. Hurley

Keyword(s):

Cardiopulmonary Bypass ◽

Aortic Valve ◽

Transcatheter Aortic Valve Implantation ◽

Meta Analysis ◽

Permanent Pacemaker ◽

Aortic Cross Clamp ◽

Transcatheter Aortic Valve ◽

Aortic Valve Implantation ◽

Valve Prostheses ◽

Valve Implantation

Objective Sutureless aortic valve prostheses are anchored by radial force in a mechanism similar to that of transcatheter aortic valve implantation. Transcatheter aortic valve implantation is associated with an increased permanent pacemaker (PPM) requirement in a significant proportion of patients. We undertook a meta-analysis to examine the incidence of PPM insertion associated with sutureless compared with conventional surgical aortic valve replacement. Methods A systematic review was conducted in accordance with the Prisma guidelines.1 All searches were performed on August 10, 2014. Studies between 2007 and 2014 were included in the search. Results A total of 832 patients were included in the sutureless group and 3,740 in the conventional group. Aortic cross-clamp (39.8 vs 62.4 minutes; P < 0.001) and cardiopulmonary bypass (64.9 vs 86.7 minutes; P = 0.002) times were shorter in the sutureless group. Permanent pacemaker implantation rate was higher in the sutureless cohort (9.1% vs 2.4%; P = 0.025). Conclusions Sutureless aortic valve prostheses are associated with significantly shorter cardiopulmonary bypass and aortic cross-clamp times and a higher incidence of PPM insertion than conventional. Further investigation of the prognostic significance is required.

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