Cardiac Tamponade Complicating Transcatheter Aortic Valve Replacement: Insights from a Single-Center Registry

Background: Cardiac tamponade complicating transcatheter aortic valve replacement (TAVR) typically results from right ventricular (RV) injury induced by a pacemaker electrode, left ventricular (LV) injury induced by guidewires and catheters used during the procedure and rupture of the aortic annulus during valve implantation.
Methods: We retrospectively analyzed our institutional TAVR database to gain mechanistic insights relating to this complication.
Results: A total of 1,247 TAVR procedures were performed between 2010-2024. Cardiac tamponade complicated 21 (1.7%) of these procedures. There was a non-significant reduction in occurrence of tamponade (1.9% among the first 623 cases vs. 1.4% among the subsequent 624 cases, p=0.44). Tamponade was caused by LV perforation in 10 cases (48%), pacemaker-induced RV perforation in 8 cases (38%) and annular rupture in 3 cases (14%). We identified 2 mechanisms causing LV perforation: the stiff guidewire used for valve delivery caused myocardial injury in 7 cases. In the 3 remaining cases, LV perforation occurred prior to insertion of the stiff guidewire and was attributed to insertion of soft guidewires. No additional such cases occurred following implementation of a protocol for meticulous guidewire insertion into the LV. Pericardiocentesis was performed in 20 patients with tamponade and cardiac surgery in 13. Nine patients (43%) died during the index hospitalization. Mortality did not differ between cases with RV perforation and left sided perforation.
Conclusions: Peri-procedural cardiac tamponade during TAVR may be caused by various mechanisms. Careful guidewire manipulation may decrease occurrence of LV perforation.