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

Suzanne 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 (Hamburg)18, M. Diab (Jena)19, M. Franz (Jena)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)18, 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)4, 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; 4Klinikum Links der Weser Klinik für Kardiologie und Angiologie 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; 18Universitäres Herz- und Gefäßzentrum Hamburg Klinik und Poliklinik für Herz- und Gefäßchirurgie Hamburg, Deutschland; 19Universitätsklinikum Jena Klinik für Herz- und Thoraxchirurgie Jena, Deutschland; 20Universitätsklinikum Jena Klinik für Innere Medizin I - Kardiologie Jena, Deutschland; 21Universitätsmedizin der Johannes Gutenberg-Universität Mainz Kardiologie 1, Zentrum für Kardiologie Mainz, 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.

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