Emergency transcatheter aortic valve replacement in patients with cardiogenic shock due to acutely decompensated aortic stenosis

Frerker, Christian; Schewel, Jury; Schlüter, Michael; Schewel, Dimitry; Ramadan, Hassan H.; Schmidt, Tobias; Tourdias, Thomas; Kreidel, Felix; Schlingloff, Friederike; Bader, Ralf; Wohlmuth, Peter; Schäfer, Ulrich; Kuck, Karl‐Heinz

doi:10.4244/eijy15m03_03

Cited by 77 publications

(78 citation statements)

References 20 publications

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“…Although we excluded non‐elective cases of TAVR in the present study, some patients who were emergently admitted for worsening HF had to be treated under serious conditions. As shown in previous research, 30‐day mortality of patients who underwent emergency TAVR was significantly higher than that of elective TAVR 20. The results of the previous study and this study suggest that treatment delay may lead to worse and poor early‐ to midterm clinical outcomes 8.…”

Section: Discussionsupporting

confidence: 73%

Patients Refusing Transcatheter Aortic Valve Replacement Even Once Have Poorer Clinical Outcomes

Shimura

Yamamoto

Kano

et al. 2018

JAHA

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BackgroundAlthough transcatheter aortic valve replacement (TAVR) is the least invasive treatment for patients with symptomatic aortic stenosis, some patients hesitate to undergo the procedure. We investigated the clinical impact of treatment delay after patient refusal of TAVR.Methods and ResultsWe used the Japanese OCEAN (Optimized Catheter valvular intervention) regsitry data of 1542 patients who underwent TAVR. Refusal was defined as at least 1 refusal of TAVR at the time of informed consent. Patients were separated into 2 groups: refusal (28/1542, 1.8%) and non‐refusal (1514/1542, 98.2%). We compared the baseline characteristics, procedural outcomes, and mortality rates between the groups. Additionally, data on reasons for refusal and those leading to eventually undergoing TAVR were collected. Age, surgical risk scores, and frailty were higher in the refusal group than in the non‐refusal group (P<0.05 for all). Periprocedural complications did not differ between groups, whereas 30‐day and cumulative 1‐year mortality were significantly higher in the refusal group than in the non‐refusal group (7.1% versus 1.3%, P=0.008 and 28.8% versus 10.3%, P=0.010, respectively). Multivariate Cox regression analysis revealed that TAVR refusal was an independent predictor of increased midterm mortality (hazard ratio: 3.37; 95% confidence interval: 1.52–7.48; P=0.003). The most common reason for refusal was fear (13/28, 46.4%), and the most common reason for changing their mind was worsening heart failure (21/28, 75.0%). All patients in the refusal group decided to undergo TAVR within 20 months (median: 5.5 months).ConclusionsRefusing TAVR even once led to poorer prognosis; therefore, this fact should be clearly discussed when obtaining informed consent.

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Section: Discussionsupporting

confidence: 73%

Patients Refusing Transcatheter Aortic Valve Replacement Even Once Have Poorer Clinical Outcomes

Shimura

Yamamoto

Kano

et al. 2018

JAHA

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“…As noted in a recent article, less than 5% of all TAVR procedures require conversion to open surgery, making this procedure both safe and feasible in high‐risk populations 19. However, in patients presenting with concomitant cardiogenic shock, TAVR is associated with nearly 33% 30‐day and 60% 1‐year mortality 20. As noted in a recent study from the Transcatheter Valve Therapy registry, nearly 10% of contemporary TAVRs are urgent or emergent and nearly 8% are performed in patients with LV ejection fraction <30% 4.…”

Section: Discussionmentioning

confidence: 99%

Periprocedural Cardiopulmonary Bypass or Venoarterial Extracorporeal Membrane Oxygenation During Transcatheter Aortic Valve Replacement: A Systematic Review

Vallabhajosyula

Patlolla

Sandhyavenu

et al. 2018

JAHA

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BackgroundThere are limited data on the use of venoarterial extracorporeal membrane oxygenation (VA‐ECMO) or cardiopulmonary bypass (CPB) to provide hemodynamic support periprocedurally during transcatheter aortic valve replacement. This study sought to evaluate patients receiving transcatheter aortic valve replacement with concomitant use of CPB/VA‐ECMO.Methods and ResultsWe systematically reviewed the published literature from 2000 to 2018 for studies evaluating adult patients requiring CPB/VA‐ECMO periprocedurally during transcatheter aortic valve replacement. Studies reporting short‐term and long‐term mortality were included. Given the significant methodological and statistical differences between published studies, meta‐analysis of the association of CPB/VA‐ECMO with mortality was not performed. Of the 537 studies identified, 9 studies representing 5191 patients met our inclusion criteria. Median ages were between 75 and 87 years with 33% to 75% male patients. Where reported, the Edwards SAPIEN™ transcatheter heart valve was the most frequently used. A total of 203 (3.9%) patients received periprocedural hemodynamic support with CPB/VA‐ECMO. Common indications for CPB/VA‐ECMO included left ventricular or aortic annular rupture, rapid hemodynamic deterioration, aortic regurgitation, cardiac arrest, and left main coronary artery obstruction. The use of CPB/VA‐ECMO was predominantly an emergent strategy and was used for durations of 1 to 2 hours. Short‐term mortality (in‐hospital and 30‐day) was 29.8%, and 1‐year mortality was 52.4%. Major complications such as bleeding, vascular injury, tamponade, stroke, and renal failure were noted in 10% to 50% of patients.Conclusions CPB/VA‐ECMO was used in 4% in the early experience of patients undergoing transcatheter aortic valve replacement, most commonly for periprocedural complications. There are limited data on preprocedural planned use of VA‐ECMO, and the characteristics of this population remain poorly defined.

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“…In the large German Aortic Valve Registry (GARY) registry reflecting real-world conditions, inhouse mortality was 5.2% 11. However, in the instance of aortic decompensation and shock, the prognosis worsens rapidly, amounting to 16% after more than one episode of pulmonary oedema12 and up to 33% in a recent study of 27 eTAVIs 13. Similarly, BAV, a procedure reportedly yielding 3.5%14 to 6.5%15 30-day mortality rates in elderly elective cases, rapidly progresses to 15% in a cohort with 7.5% shock patients16 or to ca.…”

Section: Discussionmentioning

confidence: 99%

Emergency treatment of decompensated aortic stenosis

Bongiovanni

Kühl

Bleiziffer

et al. 2017

Heart

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ObjectiveThe optimal treatment of patients with acute and severe decompensation of aortic stenosis is unclear due to recent advances in transcatheter interventions and supportive therapies. Our aim was to assess the early outcome of emergency transcatheter aortic valve implantation (eTAVI) versus emergency balloon aortic valvuloplasty (eBAV) followed by TAVI under elective circumstances.MethodsEmergency conditions were defined as: cardiogenic shock with requirement of catecholamine therapy, severe acute dyspnoea (NYHA IV), cardiac resuscitation or mechanic respiratory support. The data were collected according to the Valve Academic Research Consortium 2 (VARC-2) criteria.ResultsIn five German centres, 23 patients (logistic Euroscore 37.7%±18.1) underwent eTAVI and 118 patients underwent eBAV (logistic Euroscore 35.3%±20.8). In the eTAVI group, immediate procedural mortality was 8.7%, compared with 20.3% for the eBAV group (p=0.19). After 30 days, cardiovascular mortality for the eTAVI group was 23.8% and for the eBAV group 33.0% (p=0.40). Analyses adjusting for potential confounders did not provide evidence of a difference between groups. Of note, the elective TAVI performed after eBAV (n=32, logistic Euroscore 25.9%±13.9) displayed an immediate procedural mortality of 9.4% and a cardiovascular mortality after 30 days of 15.6%. Major vascular complications were significantly more likely to occur after eTAVI (p=0.01) as well as stroke (p=0.01).ConclusionIn this multicentre cohort, immediate procedural and 30-day mortality of eTAVI and eBAV were high, and mortality of secondary TAVI subsequent to eBAV was higher than expected. Randomised study data are required to define the role of emergency TAVI in tertiary care centres with current device generations.

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Emergency transcatheter aortic valve replacement in patients with cardiogenic shock due to acutely decompensated aortic stenosis

Abstract: TAVR should be considered a reasonable rescue therapy in patients with cardiogenic shock secondary to decompensated aortic stenosis.

Cited by 77 publications

References 20 publications

Patients Refusing Transcatheter Aortic Valve Replacement Even Once Have Poorer Clinical Outcomes

Patients Refusing Transcatheter Aortic Valve Replacement Even Once Have Poorer Clinical Outcomes

Periprocedural Cardiopulmonary Bypass or Venoarterial Extracorporeal Membrane Oxygenation During Transcatheter Aortic Valve Replacement: A Systematic Review

Emergency treatment of decompensated aortic stenosis

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