Incidence and Outcomes of Emergency Intraprocedural Surgical Conversion during Transcatheter Aortic Valve Implantation: A Multicentric Analysis

S. de Waha (Leipzig)¹, M. Marin-Cuartas (Leipzig)¹, M. De la Cuesta (Leipzig)¹, S. V. Deo (Ohio)², A. Kaminski (Karlsburg)³, A. Fach (Bremen)⁴, A. Meyer (Heidelberg)⁵, A.-F. Popov (Tübingen)⁶, C. Hagl (München)⁷, D.-S. Dohle (Mainz)⁸, D. Joskowiak (München)⁷, E. Kuhn (Köln)⁹, F. Ius (Hannover)¹⁰, F. Leuschner (Heidelberg)¹¹, G. Awad (Magdeburg)¹², H. Thiele (Leipzig)¹³, J. Garbade (Bremen)¹⁴, J. Ender (Leipzig)¹⁵, K. Wehrmann (Karlsburg)³, K. Eghbalzadeh (Köln)¹⁶, K. Vitanova (München)¹⁷, L. Conradi (Köln)¹⁸, M. Diab (Jena)¹⁹, M. Franz (Rotenburg an der Fulda)²⁰, M. Geyer (Mainz)²¹, M. Meineri (Leipzig)¹⁵, M. Misfeld (Leipzig)¹, M. Scherner (Magdeburg)¹², M. Abdel-Wahab (Leipzig)¹³, O. Bhadra (Hamburg)²², R. Osteresch (Bremen)⁴, R. Sandoval Boburg (Tübingen)⁶, R. Lange (München)⁷, R. Lange (München)¹⁷, S. Leontyev (Leipzig)¹, S. Cebotari (Hannover)¹⁰, S. Saha (München)⁷, S. Desch (Leipzig)¹³, S. Lehmann (Bremen)²³, T. Noack (Leipzig)¹, T. Doenst (Jena)¹⁹, M. A. Borger (Leipzig)¹, P. Kiefer (Leipzig)^1
1Herzzentrum Leipzig - Universität Leipzig Universitätsklinik für Herzchirurgie Leipzig, Deutschland; ²Louis Stokes Cleveland VA Medical Center, Department of Veterans Affairs Ohio, USA; ³Klinikum Karlsburg / Klinik für Herz-, Thorax- und Gefäßchirurgie Karlsburg, Deutschland; ⁴Bremer Institut für Herz- und Kreislaufforschung (BIHKF) Bremen, Deutschland; ⁵Universitätsklinikum Heidelberg Klinik für Herzchirurgie Heidelberg, Deutschland; ⁶Universitätsklinikum Tübingen Klinik für Thorax-, Herz- Gefäßchirurgie Tübingen, Deutschland; ⁷LMU Klinikum der Universität München Herzchirurgische Klinik und Poliklinik München, Deutschland; ⁸Universitätsmedizin der Johannes Gutenberg-Universität Mainz Klinik und Poliklinik für Herz- und Gefäßchirurgie Mainz, Deutschland; ⁹Universitätsklinikum Köln Klinik für Herzchirurgie, herzchirurgische Intensivmedizin und Thoraxchirurgie Köln, Deutschland; ¹⁰Medizinische Hochschule Hannover Klinik für Herz-, Thorax-, Transplantations- und Gefäßchirurgie, OE 6217 Hannover, Deutschland; ¹¹Universitätsklinikum Heidelberg Klinik für Innere Med. III, Kardiologie, Angiologie u. Pneumologie Heidelberg, Deutschland; ¹²Universitätsklinikum Magdeburg A.ö.R. Klinik für Herz- und Thoraxchirurgie Magdeburg, Deutschland; ¹³Herzzentrum Leipzig - Universität Leipzig Klinik für Innere Medizin/Kardiologie Leipzig, Deutschland; ¹⁴Klinikum Links der Weser Klinik für Herzchirurgie Bremen, Deutschland; ¹⁵Herzzentrum Leipzig / Klinik für Anästhesie Leipzig, Deutschland; ¹⁶Universitätsklinikum Köln Klinik und Poliklinik für Herz- und Thoraxchirurgie, Herzzentrum Köln, Deutschland; ¹⁷Deutsches Herzzentrum München Klinik für Herz- und Gefäßchirurgie München, Deutschland; ¹⁸Universitätsklinikum Köln Klinik und Poliklinik für Herzchirurgie Köln, Deutschland; ¹⁹Universitätsklinikum Jena Klinik für Herz- und Thoraxchirurgie Jena, Deutschland; ²⁰Herz-Kreislauf-Zentrum, Klinikum Hersfeld-Rotenburg GmbH Klinik für Kardiologie, Angiologie und Intensivmedizin Rotenburg an der Fulda, Deutschland; ²¹Universitätsmedizin der Johannes Gutenberg-Universität Mainz Kardiologie 1, Zentrum für Kardiologie Mainz, Deutschland; ²²Universitäres Herz- und Gefäßzentrum Hamburg Klinik und Poliklinik für Herz- und Gefäßchirurgie Hamburg, Deutschland; ²³Klinikum Links der Weser Klinik für Kardiologie und Angiologie Bremen, Deutschland

Background: In transcatheter aortic valve implantation (TAVI), intraprocedural complications which are only manageable by conversion to emergent open-heart surgery (E-OHS) occasionally occur. Contemporary data on the incidence and outcome of TAVI patients undergoing E-OHS are scarce. From a collaborative effort pooling data from 14 German centres, we herein present outcomes of patients undergoing E-OHS due to intraprocedural complications during TAVI.

Methods: Eligible patients underwent elective transfemoral TAVI for native aortic stenosis with intraprocedural complications requiring immediate E-OHS. Exclusion criteria were i) non-transfemoral access, ii) critical clinical status prior to TAVI with severe hemodynamic and respiratory insufficiency (e.g., cardiogenic shock, mechanical ventilation), iii) minor interventional procedures widely performed during TAVI without E-OHS (e.g. pacemaker implant, pericardiocentesis, chest tube insertion), and iv) open heart surgery performed post-TAVI procedure (e.g. TAVI explant due to paravalvular leak or infective endocarditis). All TAVI procedures were performed in hybrid operating rooms with immediate surgical backup on-site. The primary outcome was all-cause 1-year mortality. Secondary outcomes were intraprocedural mortality and in-hospital mortality.

Results: Between January 2009 and June 2021, a total of 40,557 patients underwent transfemoral TAVI at 14 German centres. Of these, 216 (0.5%) patients underwent E-OHS, and 152 patients met the inclusion criteria. The median age of this cohort was 81 years (interquartile range [IQR] 78 - 84), and 63.2% of all patients were female (n=96). The median EuroSCORE II was 7.0% (IQR 3.5 – 13.8). The proportion of patients at low risk (EuroSCORE II <4%), intermediate risk (EuroSCORE II 4 – 8%), and high risk (EuroSCORE II >8%) was 30.3% (n=46), 24.3% (n=37), and 45.4% (n=69), respectively.

Intraprocedural mortality was 12.5% (n=19), and in-hospital mortality 49.3% (n=75). While intraprocedural mortality did not differ between the risk groups (p=0.92), in-hospital mortality increased with increasing EuroSCORE II (EuroSCORE II <4%: 34.8%, EuroSCORE II 4 – 8%: 48.6%, EuroSCORE II >8%: 59.4%; p=0.04).

Overall, the Kaplan-Meier estimated rate of 1-year mortality was 57.2% (EuroSCORE II <4%: 44.4%, EuroSCORE II 4 – 8%: 55.5%, EuroSCORE II >8%: 67.5%; p=0.03). In patients surviving the index hospitalization, 1-year mortality was 15.3%. Mortality at 1 year in patients alive at hospital discharge was 12.1% in low risk patients, 13.3% in intermediate risk patients, and 21.4% in high risk patients (p=0.81).

Conclusion: Half of all patients undergoing E-OHS for a major TAVI complication survive the early postoperative period. Patients with low/intermediate surgical risk requiring E-OHS had a considerably better short-term clinical outcomes compared to patients at high surgical risk. In patients surviving the initial periprocedural period, event rates following hospital discharge after E-OHS are low. Consequently, in the setting of a Heart Team approach with immediate surgical back-up, E-OHS due to potentially lethal TAVI complications is not a futile clinical situation, with acceptable short- and long-term outcomes.