Transcatheter aortic valve replacement: Overview of complications
- William H Gaasch, MD
William H Gaasch, MD
- Section Editor — Valvular Disease
- Professor of Medicine
- University of Massachusetts Medical School
- Tufts University School of Medicine
- Senior Consultant in Cardiology
- Lahey Clinic
- Stephen JD Brecker, MD, FRCP, FESC, FACC
Stephen JD Brecker, MD, FRCP, FESC, FACC
- Section Editor — Valvular and Aortic Disease
- Chief of Cardiology
- Clinical Academic Group
- St. George's Hospital & University of London
- Gabriel S Aldea, MD
Gabriel S Aldea, MD
- Section Editor — Cardiac Surgery
- Professor of Surgery
- University of Washington
- Section Editors
- Catherine M Otto, MD
Catherine M Otto, MD
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Cardiac Evaluation; Valvular Disease
- Professor of Medicine
- University of Washington
- Donald Cutlip, MD
Donald Cutlip, MD
- Section Editor — Interventional Cardiology
- Professor of Medicine
- Harvard Medical School
- Beth Israel Deaconess Medical Center
Aortic valve replacement (AVR) is the mainstay of treatment of symptomatic aortic stenosis (AS). In properly selected patients, this surgical procedure offers substantial improvements in symptoms and life expectancy.
However, aortic valve surgery entails substantial risks for some patients with severe comorbidities, and for some considered at “extreme” risk, surgery is not appropriate. In others, technical limitations, eg, porcelain aorta (extensively calcified ascending aorta and/or aortic arch), may mean that surgery is not feasible. Percutaneous aortic valvotomy was developed as a less invasive means to treat AS but has important limitations. Subsequently developed catheter-based techniques for prosthetic aortic valve implantation provide an alternative method for treating AS in patients with intermediate or high estimated surgical risks. A multidisciplinary team approach is recommended in approaching such patients with symptomatic AS.
This topic will review complications of transcatheter aortic valve implantation, which has been termed "transcatheter AVR (TAVR or TAVI)" . Indications for AVR and TAVR, surgical AVR, estimating the risk of aortic valve surgery, medical therapy of symptomatic AS, and percutaneous aortic valvuloplasty are discussed separately. (See "Indications for valve replacement in aortic stenosis in adults" and "Transcatheter aortic valve replacement: Indications and outcomes" and "Choice of prosthetic heart valve for surgical replacement" and "Estimating the mortality risk of valvular surgery" and "Medical management of symptomatic aortic stenosis" and "Percutaneous balloon aortic valvotomy".)
Overview — Complications of transcatheter aortic valve replacement (TAVR) for native aortic valve stenosis include bleeding, shock, and low cardiac output during and following deployment, annular rupture, vascular complications, valve leaflet thrombosis, myocardial injury, heart block, paravalvular aortic regurgitation, stroke, and death.
Complications of valve-in-valve implantation for failed bioprosthetic valve are similar to those for TAVR for native aortic valve stenosis. However, rates of paravalvular regurgitation and need for permanent pacemaker implantation are much lower for valve-in-valve procedures and annulus rupture is not a reported complication of valve-in-valve implantation . Coronary artery obstruction is more frequent with valve-in-valve procedures than with native aortic valve procedures, as discussed below. (See 'Coronary obstruction' below.)
- Clegg SD, Krantz MJ. Transcatheter aortic valve replacement: what's in a name? J Am Coll Cardiol 2012; 60:239.
- Webb JG, Dvir D. Transcatheter aortic valve replacement for bioprosthetic aortic valve failure: the valve-in-valve procedure. Circulation 2013; 127:2542.
- Généreux P, Cohen DJ, Mack M, et al. Incidence, predictors, and prognostic impact of late bleeding complications after transcatheter aortic valve replacement. J Am Coll Cardiol 2014; 64:2605.
- Généreux P, Cohen DJ, Williams MR, et al. Bleeding complications after surgical aortic valve replacement compared with transcatheter aortic valve replacement: insights from the PARTNER I Trial (Placement of Aortic Transcatheter Valve). J Am Coll Cardiol 2014; 63:1100.
- Généreux P, Head SJ, Van Mieghem NM, et al. Clinical outcomes after transcatheter aortic valve replacement using valve academic research consortium definitions: a weighted meta-analysis of 3,519 patients from 16 studies. J Am Coll Cardiol 2012; 59:2317.
- Tomey MI, Mehran R. Bleeding avoidance in transcatheter aortic valve replacement: a call to ACTion? JACC Cardiovasc Interv 2014; 7:152.
- Rodés-Cabau J, Dauerman HL, Cohen MG, et al. Antithrombotic treatment in transcatheter aortic valve implantation: insights for cerebrovascular and bleeding events. J Am Coll Cardiol 2013; 62:2349.
- Holmes DR Jr, Mack MJ, Kaul S, et al. 2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement. J Am Coll Cardiol 2012; 59:1200.
- Ribeiro HB, Nombela-Franco L, Urena M, et al. Coronary obstruction following transcatheter aortic valve implantation: a systematic review. JACC Cardiovasc Interv 2013; 6:452.
- Daneault B, Kirtane AJ, Kodali SK, et al. Stroke associated with surgical and transcatheter treatment of aortic stenosis: a comprehensive review. J Am Coll Cardiol 2011; 58:2143.
- Moat NE, Ludman P, de Belder MA, et al. Long-term outcomes after transcatheter aortic valve implantation in high-risk patients with severe aortic stenosis: the U.K. TAVI (United Kingdom Transcatheter Aortic Valve Implantation) Registry. J Am Coll Cardiol 2011; 58:2130.
- Thomas M, Schymik G, Walther T, et al. Thirty-day results of the SAPIEN aortic Bioprosthesis European Outcome (SOURCE) Registry: A European registry of transcatheter aortic valve implantation using the Edwards SAPIEN valve. Circulation 2010; 122:62.
- Rodés-Cabau J, Webb JG, Cheung A, et al. Transcatheter aortic valve implantation for the treatment of severe symptomatic aortic stenosis in patients at very high or prohibitive surgical risk: acute and late outcomes of the multicenter Canadian experience. J Am Coll Cardiol 2010; 55:1080.
- Himbert D, Descoutures F, Al-Attar N, et al. Results of transfemoral or transapical aortic valve implantation following a uniform assessment in high-risk patients with aortic stenosis. J Am Coll Cardiol 2009; 54:303.
- Ewe SH, Delgado V, Ng AC, et al. Outcomes after transcatheter aortic valve implantation: transfemoral versus transapical approach. Ann Thorac Surg 2011; 92:1244.
- Smith CR, Leon MB, Mack MJ, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med 2011; 364:2187.
- Kodali SK, Williams MR, Smith CR, et al. Two-year outcomes after transcatheter or surgical aortic-valve replacement. N Engl J Med 2012; 366:1686.
- Kahlert P, Knipp SC, Schlamann M, et al. Silent and apparent cerebral ischemia after percutaneous transfemoral aortic valve implantation: a diffusion-weighted magnetic resonance imaging study. Circulation 2010; 121:870.
- Rodés-Cabau J, Dumont E, Boone RH, et al. Cerebral embolism following transcatheter aortic valve implantation: comparison of transfemoral and transapical approaches. J Am Coll Cardiol 2011; 57:18.
- Aminian A, Lalmand J, Dolatabadi D. Late contained aortic root rupture and ventricular septal defect after transcatheter aortic valve implantation. Catheter Cardiovasc Interv 2013; 81:E72.
- Eker A, Sozzi FB, Civaia F, Bourlon F. Aortic annulus rupture during transcatheter aortic valve implantation: safe aortic root replacement. Eur J Cardiothorac Surg 2012; 41:1205.
- Pasic M, Unbehaun A, Buz S, et al. Annular rupture during transcatheter aortic valve replacement: classification, pathophysiology, diagnostics, treatment approaches, and prevention. JACC Cardiovasc Interv 2015; 8:1.
- Leon MB, Smith CR, Mack M, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med 2010; 363:1597.
- Latib A, Naganuma T, Abdel-Wahab M, et al. Treatment and clinical outcomes of transcatheter heart valve thrombosis. Circ Cardiovasc Interv 2015; 8.
- De Marchena E, Mesa J, Pomenti S, et al. Thrombus formation following transcatheter aortic valve replacement. JACC Cardiovasc Interv 2015; 8:728.
- Makkar RR, Fontana G, Jilaihawi H, et al. Possible Subclinical Leaflet Thrombosis in Bioprosthetic Aortic Valves. N Engl J Med 2015; 373:2015.
- Carrabba N, Valenti R, Migliorini A, et al. Prognostic value of myocardial injury following transcatheter aortic valve implantation. Am J Cardiol 2013; 111:1475.
- Barbash IM, Dvir D, Ben-Dor I, et al. Prevalence and effect of myocardial injury after transcatheter aortic valve replacement. Am J Cardiol 2013; 111:1337.
- Koos R, Mahnken AH, Aktug O, et al. Electrocardiographic and imaging predictors for permanent pacemaker requirement after transcatheter aortic valve implantation. J Heart Valve Dis 2011; 20:83.
- Binder RK, Webb JG, Toggweiler S, et al. Impact of post-implant SAPIEN XT geometry and position on conduction disturbances, hemodynamic performance, and paravalvular regurgitation. JACC Cardiovasc Interv 2013; 6:462.
- Adams DH, Popma JJ, Reardon MJ, et al. Transcatheter aortic-valve replacement with a self-expanding prosthesis. N Engl J Med 2014; 370:1790.
- Popma JJ, Adams DH, Reardon MJ, et al. Transcatheter aortic valve replacement using a self-expanding bioprosthesis in patients with severe aortic stenosis at extreme risk for surgery. J Am Coll Cardiol 2014; 63:1972.
- Meredith Am IT, Walters DL, Dumonteil N, et al. Transcatheter aortic valve replacement for severe symptomatic aortic stenosis using a repositionable valve system: 30-day primary endpoint results from the REPRISE II study. J Am Coll Cardiol 2014; 64:1339.
- Pibarot P, Hahn RT, Weissman NJ, Monaghan MJ. Assessment of paravalvular regurgitation following TAVR: a proposal of unifying grading scheme. JACC Cardiovasc Imaging 2015; 8:340.
- Sinning JM, Vasa-Nicotera M, Chin D, et al. Evaluation and management of paravalvular aortic regurgitation after transcatheter aortic valve replacement. J Am Coll Cardiol 2013; 62:11.
- Athappan G, Patvardhan E, Tuzcu EM, et al. Incidence, predictors, and outcomes of aortic regurgitation after transcatheter aortic valve replacement: meta-analysis and systematic review of literature. J Am Coll Cardiol 2013; 61:1585.
- Mack MJ, Leon MB, Smith CR, et al. 5-year outcomes of transcatheter aortic valve replacement or surgical aortic valve replacement for high surgical risk patients with aortic stenosis (PARTNER 1): a randomised controlled trial. Lancet 2015; 385:2477.
- Kodali S, Pibarot P, Douglas PS, et al. Paravalvular regurgitation after transcatheter aortic valve replacement with the Edwards sapien valve in the PARTNER trial: characterizing patients and impact on outcomes. Eur Heart J 2015; 36:449.
- Gilard M, Eltchaninoff H, Iung B, et al. Registry of transcatheter aortic-valve implantation in high-risk patients. N Engl J Med 2012; 366:1705.
- Van Belle E, Juthier F, Susen S, et al. Postprocedural aortic regurgitation in balloon-expandable and self-expandable transcatheter aortic valve replacement procedures: analysis of predictors and impact on long-term mortality: insights from the FRANCE2 Registry. Circulation 2014; 129:1415.
- Dworakowski R, Wendler O, Halliday B, et al. Device-dependent association between paravalvar aortic regurgitation and outcome after TAVI. Heart 2014; 100:1939.
- Van Belle E, Rauch A, Vincent F, et al. Von Willebrand Factor Multimers during Transcatheter Aortic-Valve Replacement. N Engl J Med 2016; 375:335.
- Latib A, Naim C, De Bonis M, et al. TAVR-associated prosthetic valve infective endocarditis: results of a large, multicenter registry. J Am Coll Cardiol 2014; 64:2176.
- Mylotte D, Andalib A, Thériault-Lauzier P, et al. Transcatheter heart valve failure: a systematic review. Eur Heart J 2015; 36:1306.
- Sulženko J, Toušek P, Línková H. Infective endocarditis as a mid-term complication after transcatheter aortic valve implantation: case report and literature review. Catheter Cardiovasc Interv 2014; 84:311.
- Amat-Santos IJ, Messika-Zeitoun D, Eltchaninoff H, et al. Infective endocarditis after transcatheter aortic valve implantation: results from a large multicenter registry. Circulation 2015; 131:1566.
- Low cardiac output
- - Causes and management
- - Coronary obstruction
- With native aortic valve procedures
- With valve-in-valve procedures
- Stroke and subclinical brain injury
- Annular rupture
- Vascular complications
- Valve leaflet thrombosis
- Myocardial injury
- Heart block
- Post-TAVR aortic regurgitation
- - Paravalvular regurgitation
- - Central regurgitation
- Prosthetic valve endocarditis