Three-step surgical management algorithm for annular rupture in transcatheter aortic valve replacement

Kizuku Yamashita; Kazuo Shimamura; Koichi Maeda; Ai Kawamura; Masaki Taira; Daisuke Yoshioka; Shigeru Miyagawa

doi:10.1016/j.xjtc.2023.08.012

Three-step surgical management algorithm for annular rupture in transcatheter aortic valve replacement

JTCVS Tech. 2023 Aug 22:22:169-177. doi: 10.1016/j.xjtc.2023.08.012. eCollection 2023 Dec.

Authors

Kizuku Yamashita¹, Kazuo Shimamura¹, Koichi Maeda², Ai Kawamura¹, Masaki Taira¹, Daisuke Yoshioka¹, Shigeru Miyagawa¹

Affiliations

¹ Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
² Department of Minimally Invasive Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan.

Abstract

Objective: Whereas transcatheter aortic valve replacement is widely implemented, annular rupture is a devastating complication and could be highly mortal. However, owing to its rare incidence, the optimal treatment algorithm has not been established. Thus, we evaluated the feasibility and effectiveness of a 3-step algorithm to treat annulus rupture.

Methods: From 2009 to 2022, 8 patients of 1083 transcatheter aortic valve implantation (0.8%) developed annulus rupture and were treated with the three-step algorithm. The algorithm was composed of a first step (pericardial drainage and protamine neutralization with blood pressure control), second step (manual hemostatic compression via full/partial sternotomy), and a third step (conservative treatment or radical surgical correction).

Results: The median age at the procedure was 85 (78-88) years and 7 female patients were included in this study. Two (25%) patients had end-stage renal failure under hemodialysis, and median Society of Thoracic Surgeons score was 8.9% (2.1%-23.2%). The implanted transcatheter heart valves (THVs) were 7 balloon-expandable THVs and 1 self-expandable THV with balloon postdilatation. Under this strategy, 8 (100%) patients underwent pericardial drainage as first step and 5 patients achieved hemostasis. Of these, patient 1 demonstrated bleeding from left sinus of Valsalva and required a Bentall procedure. Although the etiology of this phenomenon was not investigated by contrast-enhanced computed tomography, it might be derived from pseudoaneurysm rupture or delayed annular rupture. In 2 patients, the second step treatment was needed for hemostasis. Third-step treatment was conducted in 1 patient. Postoperatively, 6 patients could be discharged without critical complications whereas 2 patients died during the hospitalization. There were no other complications during the followed-up (584 [7-1614]) days.

Conclusions: In accordance with the three-step algorithm, 6 patients, including those with high-risk or inoperative status, survived.

Keywords: annular rupture; aortic annulus rupture; transcatheter aortic valve implantation; transcatheter aortic valve replacement.