Extracorporeal Membrane Oxygenation as a Procedural Rescue Strategy for Transcatheter Aortic Valve Replacement Cardiac Complications

Abstract

Cardiovascular complications during or after transcatheter aortic valve replacement (TAVR) are associated with extremely high mortality, but extracorporeal membrane oxygenation (ECMO) can be used as procedural rescue option to improve outcomes when patients experience respiratory or cardiac arrest. From 2012 to 2014, 230 patients underwent TAVR and 10 patients (4.3%) required emergent venous-arterial ECMO support. Mean age was 83 years, median Society of Thoracic Surgeons (STS) score was 15, and mean aortic gradient was 45 mm Hg. Median left ventricular ejection fraction was 35%. Access for most ECMOs was femoral; two patients required central arterial and femoral venous access. Extracorporeal membrane oxygenation was initiated in response to hemodynamic collapse due to perforation of left ventricle (n = 2), aortic root rupture (n = 1), moderate-to-severe aortic insufficiency (n = 1), left main impingement (n = 1), valve embolization (n = 1), severe hypotension and cardiac arrest after prolonged rapid pacing sequence (n = 1), ventricular fibrillation (n = 2), and ventricular tachycardia (n = 1). Median time of ECMO support was 87 minutes. There were three hospital deaths. Post-TAVR mean aortic gradient was 8 mm Hg and median hospital stay was 19 days. Additional procedures included valve-in-valve placement (n = 1), percutaneous coronary intervention (n = 1), surgical LV repair (n = 2), surgical valve replacement (n = 1), aortic root rupture repair, and coronary bypass grafting (n = 1). Extracorporeal membrane oxygenation is rescue therapy for hemodynamic instable patients who develop TAVR-related cardiac complications.

Emergency extracorporeal membrane oxygenation in transcatheter aortic valve implantation: A two‐center experience of incidence, outcome and temporal trends from 2010 to 2015

“…We observed a mortality of 46% in patients requiring vaECMO. Previous studies on emergency vaECMO in TAVI have reported an in‐hospital mortality rate of 30% . This number is in line with other studies reporting a 30‐day mortality of patients requiring conversion to open heart surgery during TAVI of 31–45% .…”

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

“…The use of CPB/VA‐ECMO was predominantly an emergent strategy and used for durations of 1 to 2 hours except as noted in Table 3. All but 3 patients had peripheral implantation of VA‐ECMO in the studies that reported these data 11, 17. Major complications such as bleeding, vascular injury, tamponade, stroke, and renal failure were noted with varying frequency of 10% to 50% across the studies.…”

“…Of those, 9 studies representing a total of 5191 patients met the inclusion criteria (Figure and Table 1). 8, 10, 11, 12, 13, 14, 15, 16, 17 All studies except the study by Seco et al15 were retrospective studies of institutional or national databases. All studies were published from 2012 to 2017, with 7 out of 9 studies published from the United States and Europe.…”

“…The substudy of the PARTNER trial registry by Shreenivas et al was the largest study, contributing 109/203 (53.7%) patients, all of whom needed CPB 8. Commonly noted indications for CPB/VA‐ECMO included left ventricular (LV) or aortic annular rupture, rapid hemodynamic deterioration, severe aortic regurgitation, cardiac arrest from ventricular tachycardia or fibrillation, and obstruction of the left main coronary artery 8, 10, 11, 12, 13, 14, 15, 16, 17. The definition of hemodynamic deterioration varied across studies and included low cardiac output, need for high‐dose vasopressors and inotropes, prolonged pacing sequence, and severe LV dysfunction on echocardiography.…”

“…Need for high‐dose vasopressors, hemorrhagic shock, periprocedural myocardial infarction, and aortic dissection were quoted as other indications for CPB/VA‐ECMO in this population. The relative advantages of VA‐ECMO include rapid bedside access, high‐flow circuit, relatively low expense, and concomitant pulmonary support that make it an attractive option in postoperative emergencies 11. Importantly, unlike the percutaneous LV assist devices, the peripheral VA‐ECMO does not require transseptal placement or the crossing of the aortic valve 13.…”