BACKGROUND
Annular rupture is a rare but life-threatening complication of transcatheter aortic valve implantation (TAVI). Management approaches include surgical repair and conservative management, yet comparative data remain limited. This study aimed to analyze the outcome of conservative management approaches.
METHODS
We retrospectively included all patients with unequivocally identified annular rupture during TAVI procedures between 2012 and 2025. All patients had undergone pre-procedural cardiac CT for annular sizing and valve characterization. Patients were categorized according to management strategy (surgical vs. conservative).
RESULTS
Annular rupture occurred in 22 patients (mean age 85±4 years, 59% female). One patient presented with a functionally bicuspid aortic valve, while all others exhibited tricuspid morphology. All procedures had been performed via a transfemoral approach. Balloon-expandable prostheses (Edwards Sapien XT, 3 and Ultra) accounted for the majority of implanted valves (n = 19; 86% of all cases). Median prosthesis size was 26mm (IQR 23-29). Surgical repair was attempted in five patients, with a mortality rate of 100%. 17 patients were managed conservatively (mean age 86±3 years, 65% female). Reversal of anticoagulation was performed in all cases. All patients (n=20, 91%) with hemodynamic compromise due to pericardial tamponade underwent immediate pericardiocentesis. In-hospital mortality was 59% among all patients who were treated conservatively (10/17) and among 47% (8/17) patients with pericardial tamponade who were treated conservatively with percutaneous pericardiocentesis. Among conservatively treated patients, survivors (mean age 87 ± 3 years) did not differ significantly from non-survivors (85 ± 3 years; p = 0.16) regarding age or sex (57 % female vs. 70 % female; p = 0.59). Median prosthesis size was identical in both groups (26 mm [IQR 23–29]; p = 0.74). The median Agatston score was 3503 (IQR 3013–3901) in survivors versus 3406 (IQR 2496–4027) in non-survivors (p = 0.93). Median aortic annulus area and perimeter were also similar (435 mm² [IQR 419–562] vs. 451 mm² [IQR 355–552], p = 0.74; 78 mm [IQR 75–89] vs. 78 mm [IQR 70–85], p = 0.66). Post-dilatation was performed less frequently in survivors (41 % vs. 59 %; p = 0.12).
CONCLUSION
While the overall mortality rate associated with annular rupture and pericardial tamponade during the TAVI, non-surgical treatment with immediate pericardiocentesis, reversal of anticoagulation, and conservative care is an alternative to surgical management.
