Abstract
Transcatheter aortic valve replacement (TAVR) has, without a doubt, brought an unprecedented
excitement to the field of interventional cardiology. The avoidance of a sternotomy
by transfemoral or transapical aortic-valve implantation appears to come at the price
of some serious complications, including an increased risk of embolic stroke and paravalvular
leakage. The technical challenges of the procedure and the complex nature of the high-risk
patient cohort make the learning curve for this procedure a steep one, with the potential
for unexpected complications always looming. Although most commonly relating to vascular
access, these complications can also result from prosthesis-related trauma or malposition,
or from unanticipated trauma from the pacing wire or the super stiff wire. Sudden
and unexplained hypotension is often the earliest indicator of major complication
and must prompt an immediate and detailed exclusion of five major pathologies: retroperitoneal
bleeding from access site rupture, aortic dissection or rupture, pericardial tamponade,
coronary ostial obstruction, or acute severe aortic regurgitation. In most cases,
these can be dealt with quickly, and by percutaneous means, although open surgery
may occasionally be necessary. Increased operator and team experience should make
prevention and recognition of these catastrophic complications more complete. For
this reason, the importance of specific training, such as that provided by the valve
manufacturers through workshops and proctorship, cannot be overemphasized. It is essential
that all operators, and indeed all members of the implant team, exert extreme vigilance
to the development of intraprocedural complications, which could have rapid and potentially
lethal consequences. Greater experience with an improved understanding of these risks,
along with the development of better devices, deliverable through smaller and less
traumatic sheath technology, will undoubtedly improve the safety and, potentially,
widen the applicability of TAVR in the future. Forthcoming innovations include a newer
generation of the valves with operator-controlled steerability to facilitate negotiation
of tortuous aortic anatomy, as well as fully retrievable and resheathable devices
to accommodate the events of dislocation or embolization. The fact that Transcatheter
aortic valve implantation (TAVI) is new implies learning from experience but also
from mistakes. The TAVI team must be vigilant to recognize and diagnose intraprocedure
severe hypotension. The “perilous pentad” of catastrophic causes must be constantly
borne in mind: retroperitoneal bleeding from access site rupture, aortic dissection
or rupture, pericardial tamponade, coronary ostial obstruction, and acute severe aortic
insufficiency.
Key Words
Transcatheter aortic valve replacement - Complications - Aortic valve
