Abstract
Objective To identify outcomes of patients undergoing emergency transcatheter aortic valve replacement (TAVR) and determine predictors of in-hospital mortality. Background Emergency TAVR has emerged as a viable treatment strategy for patients with decompensated severe aortic stenosis and/or regurgitation; however, data on patients undergoing emergency TAVR are limited. Methods All emergency TAVR procedures were identified from a single tertiary academic center between January 2015 and August 2018. Results 31 patients underwent emergency TAVR due to cardiogenic shock (26 patients), electrical instability with incessant ventricular tachycardia (2 patients), severe refractory angina (2 patients), and decompensated heart failure with hypoxemic respiratory failure requiring mechanical ventilation (1 patient). Mechanical circulatory support (MCS) was used in 16 (51.6%). MCS initiation occurred immediately prior to TAVR in 10 patients and placed post-TAVR in 6 patients. 6 patients died before hospital discharge (in-hospital mortality 19.4%). 1-year and 2-year survival rates were 61.0% and 55.9%, respectively. Univariate predictors of in-hospital mortality were preprocedural pulmonary artery pulsatility index (PAPi) ≤1.8 (66.7% vs. 20.0%, p=0.01), intraprocedural cardiopulmonary resuscitation (CPR) (83.3% vs 4.0%, p ≤ 0.001), acute kidney injury post-TAVR (80.0% vs. 4.2%, p ≤ 0.001), initiation of dialysis post-TAVR (60.0% vs. 4.2%, p ≤ 0.001), and MCS initiation post-TAVR (50.0% vs. 12.0%, p=0.03). MCS initiation before TAVR was associated with improved survival compared with post-TAVR initiation. Conclusion Emergency TAVR in extreme risk patients with acute decompensated heart failure or cardiogenic shock secondary to severe aortic valve disease is associated with high in-hospital mortality rates. Careful patient selection taking into account right heart function, assessed by PAPi, and early utilization of MCS may improve survival following emergency TAVR.
Highlights
Acute decompensated heart failure or cardiogenic shock due to severe aortic stenosis (AS) portends a dismal diagnosis, and operative risk in these patients is exceedingly high [1, 2]
transcatheter aortic valve replacement (TAVR) has been successfully established as the treatment for patients with severe AS who are at prohibitive or high risk for surgical aortic valve replacement [4, 5] and is emerging as a viable treatment strategy in the urgent/emergency setting for hemodynamically unstable patients [6]. e largest study to date, utilizing the Society of oracic Surgeons/American College of Cardiology Transcatheter Valve (STS/ACC TVT) Registry, reported favorable 30-day and 1-year outcomes of 3,952 patients when combining urgent and emergency TAVR procedures; emergency TAVR cases represented only 0.2% of the study population, and salvage cases were excluded [6]. us, results from this registry-based study are not re ective of emergency TAVR outcomes
Emergency TAVR was performed due to refractory cardiogenic shock (26 patients); electrical instability with incessant ventricular tachycardia (2 patients); severe unrelenting angina despite medical therapy (2 patients); and decompensated heart failure with refractory hypoxemic respiratory failure requiring mechanical ventilation (1 patient)
Summary
Acute decompensated heart failure or cardiogenic shock due to severe aortic stenosis (AS) portends a dismal diagnosis, and operative risk in these patients is exceedingly high [1, 2]. Catheter-based procedures such as emergency balloon aortic valvuloplasty and emergency transcatheter aortic valve replacement (TAVR) have provided alternative treatment options in these unstable, high-risk patients. Balloon aortic valvuloplasty has been proposed as a therapy to allow a bridge to treatment or to decision, but carries risks for strokes and vascular complications and may not be su cient to stabilize a decompensated patient [3]. TAVR has been successfully established as the treatment for patients with severe AS who are at prohibitive or high risk for surgical aortic valve replacement [4, 5] and is emerging as a viable treatment strategy in the urgent/emergency setting for hemodynamically unstable patients [6]. TAVR has been successfully established as the treatment for patients with severe AS who are at prohibitive or high risk for surgical aortic valve replacement [4, 5] and is emerging as a viable treatment strategy in the urgent/emergency setting for hemodynamically unstable patients [6]. e largest study to date, utilizing the Society of oracic Surgeons/American College of Cardiology Transcatheter Valve (STS/ACC TVT) Registry, reported favorable 30-day and 1-year outcomes of 3,952 patients when combining urgent and emergency TAVR procedures; emergency TAVR cases represented only 0.2% of the study population, and salvage cases were excluded [6]. us, results from this registry-based study are not re ective of emergency TAVR outcomes.
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