Aortic dissection associated with transcatheter aortic valve replacement: Implications of preexisting aortic pathologies

Objectives: Acute aortic dissection is a rare yet life-threatening complication associated with transcatheter aortic valve replacement (TAVR). Given its low incidence, the characteristics and risk factors remain inadequately investigated. Methods: Between 2011 and 2023, a total of 2558 TAVR procedures were performed at the University of Michigan. Among these, 12 patients (0.47%) developed aortic dissection. Additionally, 3 post-TAVR patients from other institutions presented with aortic dissection and were treated at our institution, yielding a total of 12 type A and 3 type B aortic dissections. Results: The median age was 79.5 years, and 5 (33.3%) exhibited end-organ malperfusion affecting the brain (n = 3), legs (n = 3), and kidneys (n = 1). TAVR device migration requiring repositioning was observed in 40% (6 out of 15) of cases. In type A dissections, the entry tear consistently occurred along the greater curvature. Patients with type A dissections had a larger pre-TAVR aortic diameter than those without dissection (41.6 mm vs 34.5 mm; P < .001). Preexisting aortic dilation (≥45 mm) was associated with a significantly increased risk of type A dissection (odds ratio, 12.0; 95% confidence interval 3.0-50.6; P < .001). Type A dissection was managed with open repair in 7 patients (58.3%), all of whom survived 30 days, and with endovascular aortic repair in 4 patients (33.3%), all of whom experienced mortality; 1 patient received palliative care. All type B dissections were successfully treated with endovascular repair. Conclusions: TAVR-related aortic dissection is characterized by preexisting aortic risk factors with various mechanisms. Current surgical guidelines recommending aortic repair for dilatation ≥45 mm should be strongly considered in patients undergoing TAVR evaluation.