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You are here: Contents > 2013 > Volume 22 Number 3 May 2013 > AORTIC VALVE DISEASE > Prevention and Management of Potential Adverse Events During Transapical Aortic Valve Replacement

Prevention and Management of Potential Adverse Events During Transapical Aortic Valve Replacement

Ludwig K. von Segesser1, Gino Gerosa2, Michael A. Borger3, Enrico Ferrari1

1Cardiovascular Surgery Unit, University of Lausanne, Switzerland, 2Cardiac Surgery Unit, Policlinico universitario, Padova, Italy, 3Leipzig Heart Center, University of Leipzig, Germany

Background and aim of the study: Transapical transcatheter aortic valve replacement (TAVR) is a new minimally invasive technique with a known risk of unexpected intra-procedural complications. Nevertheless, the clinical results are good and the limited amount of procedural adverse events confirms the usefulness of a synergistic surgical/anesthesiological management in case of unexpected emergencies.

Methods: A review was made of the authors’ four year database and other available literature to identify major and minor intra-procedural complications occurring during transapical TAVR procedures. All implants were performed under general anesthesia with a balloon-expandable Edwards Sapien™ stent-valve, and followed international guidelines on indications and techniques.

Results: Procedural success rates ranged between 94% and 100%. Life-threatening apical bleeding occurred very rarely (0-5%), and its incidence decreased after the first series of implants. Stentvalve embolization was also rare, with a global incidence ranging from 0-2%, with evidence

of improvement after the learning curve. Rates of valve malpositioning ranged from 0% to <3%, whereas the risk of coronary obstruction ranged from 0% to 3.5%. Aortic rootrupture and dissection were dramatic events reported in 0-2% of transapical cases. Stentvalve malfunction was rarely reported (1-2%), whereas the valve-in-valve bailout procedure for malpositioning, malfunctioning or severe paravalvular leak was reported in about 1.0-3.5% of cases. Sudden hemodynamic management and bailout procedures such as valve-in-valve rescue or cannulation for cardiopulmonary bypass were more effective when planned during the preoperative phase.

Conclusion: Despite attempts to avoid pitfalls, complications during transapical aortic valve procedures still occur. Preoperative strategic planning, including hemodynamic status management, alternative cannulation sites and bailout procedures, are highly recommended, particularly during the learning curve of this technique.

The Journal of Heart Valve Disease 2013;22:276-286

Prevention and Management of Potential Adverse Events During Transapical Aortic Valve Replacement

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