Annular rupture in TAVI: considerations on the importance of on-site cardiothoracic surgery

Transcatheter aortic valve implantation (TAVI) has proven itself as an effective equivalent to surgical aortic valve replacement for patients with aortic stenosis. However, there is a recognised risk profile for TAVI. Complications such as aortic rupture may require bailout emergency cardiac surgery. Current guidelines dictate the presence of on-site cardiac surgery in centres providing TAVI. However, recent reports suggest that there may be a benefit from increasing access to TAVI to centres without cardiac surgery, the aim of which would be to reduce the morbidity and mortality of patients awaiting TAVI. A decision to do so may accept a degree of risk – patients who suffer complications without access to cardiac surgery would have no recourse for management. This case report exemplifies the risk being taken and reviews the relevant considerations and emerging research. An 80-year-old female presented to her GP with symptoms of heart failure and systolic murmur. Aortic stenosis was confirmed with echocardiogram and a plan for TAVI was made. The patient underwent TAVI but suffered an annular rupture causing pericardial tamponade after valve deployment. Rapid conveyance to the operating theatre and cardiac surgery permitted the patient’s survival. The conversion to open surgical repair was successful. After two months the patient was reviewed and noted to have recovered well. The importance of on-site cardiac surgery is highlighted by this case. The patient was at an increased risk of annular rupture due to calcified bicuspid aortic valve anatomy and deemed a suitable candidate for emergency cardiac surgery. The risk of a complication that might be salvaged by emergency cardiac surgery, and patient suitability for emergency cardiac surgery, will be essential considerations if TAVI in non-surgical centres is to become more commonplace. If offered, this could ease the burden of morbidity and mortality of patients awaiting TAVI, but only if it can be offered without neglecting those who may benefit from cardiac surgery.