Impact of Surgical Timing on Mortality in Complex TAVR Bailout Cases
Overview
In a single-centre study of 3039 TAVR procedures, emergent surgical bailout was required in 0.53% of cases. Mortality was significantly lower when procedures were performed in a hybrid operating room (HOR) with immediate surgical availability (33.3%) compared to a standard catheterisation lab (CCL) with delayed surgery (100%). The critical factor influencing survival was the time from complication onset to surgical incision.
Background
Transfemoral transcatheter aortic valve replacement (TAVR) is associated with a low incidence of serious periprocedural complications necessitating emergent conversion to open-heart surgery, termed surgical bailout. Although bailout rates have declined to below 1%, mortality after such events remains high, exceeding 50%. Current guidelines recommend TAVR be performed in centres with on-site cardiac surgery to enable rapid surgical intervention. However, data on how procedural timing and hospital infrastructure impact outcomes are limited.
Data Highlights
Parameter
CCL Group (n=10)
HOR Group (n=6)
P Value
Bailout Rate
1.42%
0.26%
Not reported
Median Age (years)
88 [85–90]
83 [71–85]
≤ 0.001
Female Patients
90%
33%
0.036
In-hospital Mortality
100%
33.3%
< 0.01
Time from Procedure Start to Complication (min)
93 [70–117]
81 [52–88]
0.316
Time from Complication to ECLS Initiation (min)
35 [27–41]
23 [20–27]
0.063
Time from Complication to Surgical Incision (min)
110 [109–114]
39 [33–45]
0.010
Key Findings
Emergent surgical bailout occurred in 0.53% of TAVR procedures, with a higher incidence in the CCL era (1.42%) compared to the HOR era (0.26%).
In-hospital mortality was 100% in the CCL group versus 33.3% in the HOR group (P < 0.01).
Time from complication onset to surgical incision was significantly shorter in the HOR group (median 39 min) compared to the CCL group (median 110 min; P = 0.010).
All patients in the HOR group underwent successful surgical intervention, while only 40% of CCL patients reached the OR and 20% completed surgery.
Procedure-related deaths occurred exclusively in the CCL group; deaths in the HOR group were due to non-procedure-related causes.
Haemodynamic instability prior to surgery was more frequent in the CCL group, with all requiring ECLS before incision versus 50% in the HOR group.
Clinical Implications
Performing TAVR in a hybrid operating room with immediate surgical backup significantly reduces mortality in cases requiring emergent surgical bailout. Rapid surgical intervention following complication onset is critical to improving survival. These findings support guideline recommendations for TAVR centres to have on-site cardiac surgery and highlight the importance of infrastructure that enables prompt surgical rescue.
Conclusion
This study demonstrates that shorter time to surgical intervention during complex TAVR complications markedly improves survival. Embedding TAVR procedures within hybrid operating rooms with co-located surgical teams is a key modifiable factor to reduce mortality in emergent bailout cases.
References
Compagnone et al. 2024 -- Great Debate on TAVR Centre Requirements
2024 Guidelines for TAVR Indications and Centre Requirements
by Tobias Zeus, Ayse S. Ceylan, Kathrin Klein, Christian Jung, Amin Polzin, Bedri Ramadani, Maximilian Scherner, Christina Ballazs, Dmytro Stadnik, Stephan Sixt, Peter Kienbaum, Artur Lichtenberg, Malte Kelm
