title: Emergency use of cardiopulmonary bypass in complicated transcatheter aortic valve replacement: importance of a heart team approach.
abstract: Transcatheter aortic valve replacement (TAVR) expands options for high-risk patients with aortic stenosis but is complex with life-threatening complications. We describe indications for use of salvage cardiopulmonary bypass (CPB) and assess outcomes.
  
  
  
  From 2006 to 2011, 303 patients underwent TAVR, and 12 (4%) required emergency CPB. Approach was transapical (9) and transfemoral (3). Mean age was 82±9 years, median Society of Thoracic Surgeons score was 11 and mean gradient was 46±9 mm Hg. Access for CPB was femoral under fluoroscopy. Principal indication for CPB was hemodynamic instability with or without ischemic changes. These resulted from aortic insufficiency (n=5), valve embolization (n=3), coronary malperfusion (n=2), bleeding requiring pericardiocentesis (n=1), and bleeding from ventricular apex (n=1). Additional procedures included valve-in-valve TAVR (n=5), surgical valve replacement (n=3), and coronary intervention (n=2). Additional circulatory support was used in 7 cases: intra-aortic balloon pump (5) and extracorporeal membrane oxygenation (3).
  
  
  
  There were 2 hospital deaths. Mean postoperative gradient was 12±9 mm Hg, and median stay was 16 days. There were no myocardial infarctions or renal failure. One patient had stroke with arm weakness, 2 required tracheostomy, and 2 underwent reoperations for bleeding. Median follow-up was 19 months, and there were 5 late deaths.
  
  
  
  Complications during TAVR can be life threatening and may necessitate additional procedures. Expeditious use of CPB support provided by a multidisciplinary heart team optimizes rescue after myocardial collapse.
authors: Departments of Thoracic and Cardiovascular Surgery and Interventional Cardiology, Heart and Vascular Institute, The Cleveland Clinic, Cleveland, Ohio. Electronic address: roselle@ccf.org.
authors: Eric E
authors: EE
authors: Roselli
authors: Departments of Thoracic and Cardiovascular Surgery and Interventional Cardiology, Heart and Vascular Institute, The Cleveland Clinic, Cleveland, Ohio.
authors: Jay
authors: J
authors: Idrees
authors: Departments of Thoracic and Cardiovascular Surgery and Interventional Cardiology, Heart and Vascular Institute, The Cleveland Clinic, Cleveland, Ohio.
authors: Stephanie
authors: S
authors: Mick
authors: Departments of Thoracic and Cardiovascular Surgery and Interventional Cardiology, Heart and Vascular Institute, The Cleveland Clinic, Cleveland, Ohio.
authors: Samir
authors: S
authors: Kapadia
authors: Departments of Thoracic and Cardiovascular Surgery and Interventional Cardiology, Heart and Vascular Institute, The Cleveland Clinic, Cleveland, Ohio.
authors: Murat
authors: M
authors: Tuzcu
authors: Departments of Thoracic and Cardiovascular Surgery and Interventional Cardiology, Heart and Vascular Institute, The Cleveland Clinic, Cleveland, Ohio.
authors: Lars G
authors: LG
authors: Svensson
authors: Departments of Thoracic and Cardiovascular Surgery and Interventional Cardiology, Heart and Vascular Institute, The Cleveland Clinic, Cleveland, Ohio.
authors: Bruce W
authors: BW
authors: Lytle
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D002315:Cardiopulmonary Bypass / Q000401:mortality; D004452:Echocardiography; D004630:Emergencies; D005260:Female; D006801:Humans; D008297:Male; D010348:Patient Care Team / Q000458:organization & administration*; D011183:Postoperative Complications / Q000401:mortality; D012307:Risk Factors; D065467:Transcatheter Aortic Valve Replacement / Q000401:mortality; D016896:Treatment Outcome