title: Emergency cardiac surgery during transfemoral and transapical transcatheter aortic valve implantation: incidence, reasons, management, and outcome of 411 patients from a single center.
abstract: OBJECTIVE
  Transcatheter aortic valve implantation (TAVI) is increasingly performed in high-risk patients with severe aortic valve stenosis. Incidence and impact of emergency cardiac surgery (ECS) during TAVI is unclear.
  
  
  RESULTS
  Two-hundred twenty one transapical (TA) and 190 transfemoral (TF) TAVIs were performed at our hospital between 01/2009 and 12/2012. Twenty patients (4.9%) required ECS, more frequently in the TF- (n = 11; 5.8%) than in the TA-group (n = 9; 4.1%; P = 0.017). ECS-cases were evenly distributed throughout the 4 years. Baseline characteristics of the ECS-patients were not different from the non-ECS-patients. Reasons were acute cardiac failure, coronary obstruction, annular rupture, valve migration, right- and left-ventricular perforation, severe paravalvular leakage, aortic dissection, and mitral valve damage. Surgical intervention consisted of peripheral CPB, switch to TA, thoracotomy and suture of perforated cardiac chambers and conventional aortic valve replacement with concomitant repair of associated cardiovascular injury. Thirty-day mortality was 35.0%, and 55.0% could be salvaged to hospital discharge. Kaplan-Meier 1-year survival curves were significantly impaired for patients requiring ECS (TF: P < 0.0001, HR 8.716; TA: P = 0.013, HR 2.813).
  
  
  CONCLUSIONS
  Life-threatening complications requiring bail-out ECS occur in a substantial proportion during TAVI. ECS dramatically affects early and late outcome after TAVI. Under optimal conditions more than half of the ECS-patients can be salvaged. With the current technology of THV-systems ECS should be an integral part of the logistic conditions surrounding TAVI and is far from being futile in this patient population.
authors.affiliation: Department of Cardiology, Cardiovascular Center Bad Neustadt, Bad Neustadt a.d., Saale, Germany.
authors.forename: Daniel P
authors.initials: DP
authors.lastname: Griese
authors.forename: Wilko
authors.initials: W
authors.lastname: Reents
authors.forename: Sebastian
authors.initials: S
authors.lastname: Kerber
authors.forename: Anno
authors.initials: A
authors.lastname: Diegeler
authors.forename: Jörg
authors.initials: J
authors.lastname: Babin-Ebell
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D006328:Cardiac Catheterization / Q000009:adverse effects* / Q000379:methods / Q000401:mortality; D002315:Cardiopulmonary Bypass; D004630:Emergencies; D005260:Female; D005263:Femoral Artery; D005858:Germany; D006335:Heart Injuries / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects* / Q000379:methods / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D015994:Incidence; D053208:Kaplan-Meier Estimate; D008297:Male; D010351:Patient Discharge; D016016:Proportional Hazards Models; D012307:Risk Factors; D012720:Severity of Illness Index; D013536:Suture Techniques; D013908:Thoracotomy; D013997:Time Factors; D016896:Treatment Outcome
keywords: cardiopulmonary support; complications adult cath/intervention; valvular heart disease