Emergent cardiac surgery during transcatheter aortic valve implantation (TAVI): insights from the Edwards SAPIEN Aortic Bioprosthesis European Outcome (SOURCE) registry

Aims: Transcatheter aortic valve implantation (TAVI) carries the risk of intraprocedural complications that may ultimately require emergent cardiac surgery (ECS). However, few data exist on the incidence, reasons and outcomes of patients needing ECS during TAVI. We analysed data from 2,307 TAVI patients, prospectively enrolled in the multicentre Edwards SAPIEN Aortic Bioprosthesis European Outcome (SOURCE) registry. Methods and results: Twenty-seven (1.2%) of 2,307 patients required ECS. The rates of ECS were similar for patients undergoing transapical TAVI compared with transfemoral TAVI (1.1% vs. 1.2%). The leading causes for ECS were embolisation/migration of the TAVI valve prosthesis (9/27, 33%) and procedure-related aortic injury (n=7, 26%). Thirty-day mortality of ECS was high (51.9%) and showed cause-specific differences, with 100% mortality in patients with aortic rupture or cardiac tamponade, 0% death in those with acute aortic regurgitation and intermediate risk of death or intermediate mortality in those with aortic injury or valve embolisation/migration. Conclusions: Rates of ECS during TAVI were low (1.2%). Although ECS was performed without time delay, emergent surgery was associated with a 30-day mortality of 52%. Complications with dramatic acute consequences (annular rupture, aortic injury) had higher mortality than those with less acute deterioration (aortic regurgitation). Prevention of complications requiring ECS during TAVI appears to be of critical importance, focusing on less traumatic, more flexible delivery catheter systems and retrievable valves to reduce the risk of aortic injury and valve embolisation, the two most common causes of ECS.