Objectives:
Patients undergoing trans-catheter aortic valve implantation (TAVI) are considered high-risk or declined for conventional cardiac surgery. Following unsuccessful TAVI patients are managed conservatively, taken emergently to the operation theater, or refereed later for surgery. Our objective was analyzing prevalence and outcome of surgery after failed TAVI.
Methods:
Our study is a multicenter retrospective data collection, of patients that underwent TAVI and referred later for open-heart surgery.
Results:
From 2009, 2516 TAVI procedure were performed in Israel (1350 Corevalve, 1150 Sapien, 16 other). We identified 26 patients, requiring surgical intervention following TAVI (17 Corevalve, 8 Sapien and Portico in 1). TAVI approach was trans-femoral in 22, trans-apical in 3 and trans-axillary in 1.
There were 12 emergency (within 24 hours) and 14 non-emergency cases: 4 urgent (same hospitalization) and 10 at later stage.
Non-emergency procedures included: AVR in 7; MVR±TV±CABG in 5 and explorative sternotomy in 2.
In the 12 patients that needed explantation of the TAVI device due to AR (9 Corevalve, 3 Sapien), explantation was technically successful in all, and surgical bioprosthesis was implanted. None of the patients needed aortic root replacement. Mean and median time-to-intervention in delayed AVR was 127 and 56 days (7-358).
Overall mortality was 46% (12/26): emergency 50% (6/12), urgent 100% (4/4) and delayed 20% (2/10).
In cases requiring AVR overall mortality was 33% (4/12): 20% in emergency (1/5); 100% in urgent (2/2) and 20% in delayed (1/5).
Conclusions:
Unsuccessful TAVI requiring surgical intervention carries significant mortality and morbidity, mainly in emergency and urgent cases. However, in cases with significant AR, TAVI device can be safely explanted and replaced by surgical bioprosthesis with acceptable outcome. Immediate intervention (to prevent end organ injury due to AR) or semi elective timing in stable patients has the best favorable outcome.
