Facing Complexity: Outcomes of Surgical Bailouts from Complications of Transcatheter Aortic Valve Replacement in a Single High-Volume Center

<b>Background:</b> Transcatheter aortic valve replacement (TAVR) is at the forefront of structural heart programs all over the world. With a growing number of TAVR procedures in lower-risk and younger patients, acute and chronic complications require decisive treatment. The aim of the present study is to retrospectively analyze the efficacy of surgical bailout strategies in case of complications from TAVR that had been performed in the highest-volume center in Italy over the past ten years. <b>Methods:</b> Acute complications were defined as events occurring in the first 24 h after surgery, while chronic complications were defined as events occurring within the first year post-implant. We retrospectively analyzed the 2731 patients who had undergone TAVR at our institution from January 2015 to August 2024. <b>Results:</b> A total of 21 patients were included, with a median age of 78 years (IQR 11y). The majority of patients underwent TAVR with a self-expanding prosthesis (76%). A total of 11 patients (52%) presented acute complications, of which the most common were aortic dissection (<i>n</i> = 4 [19%]) followed by left ventricular perforation (<i>n</i> = 3 [14%]). The most common chronic complication was early endocarditis (<i>n</i> = 5 [24%]). The most common bailout strategy was aortic valve replacement (AVR), which was sufficient in 10 patients (48%), followed by complete root replacement (<i>n</i> = 4 [19%]). In-hospital mortality was higher in acute compared with chronic complications albeit not statistically significant (<i>n</i> = 4 [36%] vs. <i>n</i> = 2 [20%], <i>p</i> = 0.64), highlighting the very high risk of all these surgeries. <b>Conclusions:</b> Bailout and post-TAVR surgery are critical issues, with overall acceptable yet significant mortality considering the very high risk of these procedures. In our experience, half of the overall complications cannot be resolved with a simple explant and subsequent valve replacement, thereby underlining the importance of skilled cardiothoracic surgery teams on site to address complex issues such as ventricular perforation and emergency aortic/root replacement.