Rupture of the aortic ring during transcatheter aortic valve implantation: prevention and management of complication

Aortic annulus rupture is a dangerous complication of transcatheter aortic valve implantation, with an overall incidence of around 1%. Ruptures can be distinguished into supra-annular, involving injuries of the sinus of Valsalva and the sinotubular junction, annular, involving the fibrous portion of the aortic annulus, and sub-annular, located in the left ventricular outflow tract below the aortic valve cusp insertion. Annular rupture can be "contained", which usually evolves in aortic hematoma or pseudoaneurysm and rarely requires emergent cardiac surgery; or "non-contained", acutely evolving in hemopericardium with cardiac tamponade, often requiring emergent cardiac surgery and with an in-hospital mortality of 75%. Balloon-expandable oversizing and severe left ventricular outflow tract calcifications, especially under the left coronary cusp, are the most important risk factors for annular rupture. A careful computed tomography scan-based procedural planning is of paramount importance to reduce the risk of this complication. The presence and extension of left ventricular outflow tract calcifications, together with precise measurement of the virtual basal ring, should drive the operator to the right choice of prosthesis type and size in order to prevent this terrible complication.