Unexpected complications of transapical aortic valve implantation.
BACKGROUND
Recent series have reviewed the results of transapical aortic valve implantation (TAVI). However, specific problems of this new procedure are not well-described. Unexpected complications due to the procedure and their management are reported.


METHODS
Eighteen patients underwent TAVI using the Edwards Sapien bioprosthesis (Edwards Lifesciences Inc, CA) between September 2007 and June 2008 due to contraindications of conventional surgery (n = 5) or high operative risk (n = 13). The system was introduced through 2 purse string sutures in the apex under echocardiographic and fluoroscopic control.


RESULTS
The implantation success rate and initial procedural success were 100%. There was no intraoperative death and no stroke. During the procedure, two cases of ventricular fibrillation consequent to rapid pacing were treated by cardioversion. Acute mitral regurgitation due to traction of the subvalvular apparatus by the guidewire and acute aortic regurgitation from pressure on a bioprosthesis cusp by the guidewire were diagnosed by transesophageal echocardiography and reversed by the removal of the guidewire. Another case of aortic regurgitation was due to incomplete deployment of the bioprosthesis and was managed by a "valve after valve" procedure. Two patients died on postoperative day 2 from left ventricular failure. In one patient the postmortem study showed, despite correct implantation of the bioprosthesis, a hematoma of the septum with a small ventricular septal defect. The total in-hospital death was 27.7% (5 patients). There was no periprocedural bleeding but in one patient delayed rupture of the apex (36 hours after the procedure) necessitated emergency surgery. A false aneurysm of the apex appeared 3 months after surgery in another patient. Closure of the apex was performed through sternotomy and cardiopulmonary bypass with an uneventful follow-up.


CONCLUSIONS
The TAVI is associated with incidents and complications different to those encountered in conventional aortic valve surgery. Recognizing their existence contributes to elucidating their mechanisms and to propose solutions to avoid or treat them.
Al-Attar
Nawwar
N
Department of Cardiovascular Surgery, Bichat - Claude Bernard Hospital, Paris, France.
Ghodbane
Walid
W
Himbert
Dominique
D
Rau
Céderic
C
Raffoul
Richard
R
Messika-Zeitoun
David
D
Brochet
Eric
E
Vahanian
Alec
A
Nataf
Patrick
P
D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001705:Bioprosthesis; D006328:Cardiac Catheterization / Q000379:methods; D002423:Cause of Death; D015331:Cohort Studies; D017548:Echocardiography, Transesophageal; D005260:Female; D005500:Follow-Up Studies; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects* / Q000379:methods; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D007431:Intraoperative Complications / Q000175:diagnosis* / Q000628:therapy; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods; D008944:Mitral Valve Insufficiency / Q000209:etiology / Q000628:therapy; D011183:Postoperative Complications / Q000175:diagnosis / Q000401:mortality; D018570:Risk Assessment; D015996:Survival Rate; D014693:Ventricular Fibrillation / Q000175:diagnosis / Q000628:therapy