Original title: Emergent cardiac surgery during transcatheter aortic valve implantation (TAVI): insight from Edwards SAPIENS Aortic Bioprótesis European Outcome (SOURCE) registry Reference: Holger Eggebrecht, et; al. Eurointervention 2013; 9online publish-ahead of print november 2013

Percutaneous aortic valve implantation has grown significantly since its inception, to be a safe procedure. The need for emergency cardiac surgery is rare, its causes and impact still little known. 

2307 patients from SOURCE Registry were analyzed, of whom 27 (1.2 %) required emergency surgery. Most of these were women and more frequent access was trans-apical (16/ 59%), there was no difference in other points with the rest of the population. The most frequent cause was embolization / migration (9/ 33%) followed by aortic dissection and perforation lesions (7/26 %). Other causes were aortic annulus rupture (3/ 11%), severe percutaneous valvular insufficiency (3/11), cardiac tamponade (2/7 %), apical access bleeding (1/4 %),    coronary obstruction (1 / 4%) and failure in the release process (1/ 4%). Immediate mortality    (within 72 hours, VARC -2) occurred in 10 patients (37 %) and after 30 days at 51.9 % compared with 7.6 % in the rest of the population. Mortality after the first month reaches 70 %. Death was associated to the cause that motivates surgery, so 3 patients showed rupture of the aortic annulus died the 2 patients with severe cardiac tamponade, 7 with migration / embolism and 4 who had aortic lesions. The most common cause of death after surgery was low cardiac volume minute / cardiogenic shock, followed by multiple organ failure, bleeding and stroke.

Conclusion

The rate of emergency surgery is low, with a mortality of 52% after 30-day. Acute dramatic complications (ring rupture or aortic injury) have a high mortality. Preventing complications requiring emergency surgeries are important, in that way, less traumatic and more flexible devices reduce the risk of aortic injury and migration; these being the two most common causes. 

Comment

TAVI has proven effective and safe, and the need for surgery is rare (between 0.1 % and 1.2 %), but having a strong negative impact on the short- term. It is essential to have an excellent surgeon and heart team experience, when indicate and perform these interventions. Surely, with the development of new and better valves the need for emergency surgery will decrease. 

Courtesy of Dr Carlos Fava
Interventional cardiologist
Fundación Favaloro – Argentina

Dr. Carlos Fava para SOLACI.ORG