Clinical Scorecard: Duration until surgical intervention and associated mortality in complex transcatheter aortic valve replacement cases
At a Glance
Category
Detail
Condition
Emergent surgical bailout during transfemoral transcatheter aortic valve replacement (TAVR)
Key Mechanisms
Periprocedural complications requiring immediate conversion to open-heart surgery, including ventricular perforation, annular rupture, thoracic aortic injury, and valve malposition
Target Population
Patients undergoing transfemoral TAVR, particularly elderly patients (median age 84 years) with complex cases
Care Setting
TAVR centres with either standard cardiac catheterisation laboratories (CCLs) or purpose-built hybrid operating rooms (HORs) with on-site cardiac surgery teams
Key Highlights
Emergent surgical bailout occurred in 0.53% of 3039 TAVR procedures, with a lower incidence in HOR settings (0.26%) compared to CCL (1.42%).
In-hospital mortality after surgical bailout was 100% in the CCL group versus 33.3% in the HOR group, highlighting the impact of immediate on-site surgical intervention.
Time from complication to surgical incision was significantly shorter in the HOR group (median 39 minutes) compared to the CCL group (median 110 minutes), correlating with improved survival.
Guideline-Based Recommendations
Diagnosis
Identify critical periprocedural complications during TAVR requiring emergent surgical bailout, such as ventricular perforation and annular rupture.
Management
Perform TAVR procedures in centres embedded within cardiac surgery departments providing 24/7 surgical services.
Utilize hybrid operating rooms to enable immediate on-site surgical rescue and extracorporeal life support (ECLS) initiation.
Monitoring & Follow-up
Monitor haemodynamic stability closely during TAVR to detect complications early and initiate timely ECLS and surgical intervention.
Risks
Recognize that delayed surgical intervention after bailout complications is associated with high mortality (>50%).
Understand that absence of on-site cardiac surgery infrastructure significantly increases procedure-related mortality.
Patient & Prescribing Data
Elderly patients undergoing transfemoral TAVR, median age 84 years, predominantly female in CCL group
Immediate surgical intervention in a hybrid OR setting reduces mortality; delayed transfer to distant OR increases risk of death.
Clinical Best Practices
Conduct TAVR in hybrid operating rooms with co-located multidisciplinary teams prepared for immediate surgical bailout.
Initiate extracorporeal life support promptly upon complication detection to stabilize patients before surgery.
Minimize time from complication onset to surgical incision to improve survival outcomes.
Ensure continuous availability of cardiac surgery services during TAVR procedures.
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
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