title: Prevention and management of potential adverse events during transapical aortic valve replacement.
abstract: OBJECTIVE
  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. Stent-valve 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 root rupture and dissection were dramatic events reported in 0-2% of transapical cases. Stent-valve 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Cardiovascular Surgery Unit, University of Lausanne, Switzerland.
authors.forename: Ludwig K
authors.initials: LK
authors.lastname: von Segesser
authors.forename: Gino
authors.initials: G
authors.lastname: Gerosa
authors.forename: Michael A
authors.initials: MA
authors.lastname: Borger
authors.forename: Enrico
authors.initials: E
authors.lastname: Ferrari
mesh_terms: D001021:Aortic Valve / Q000503:physiopathology / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D005858:Germany; D006334:Heart Function Tests / Q000379:methods; D006350:Heart Valve Prosthesis / Q000009:adverse effects / Q000592:standards; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods / Q000706:statistics & numerical data; D006801:Humans; D007430:Intraoperative Care / Q000379:methods; D007431:Intraoperative Complications / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control; D016343:Monitoring, Intraoperative / Q000379:methods; D010043:Outcome and Process Assessment, Health Care; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D015607:Stents / Q000009:adverse effects / Q000592:standards