Ann Thorac Surg 2009;88:94. doi:10.1016/j.athoracsur.2009.04.053
© 2009 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Invited Commentary
Fraser W.H. Sutherland, MD, FRCS(Eng)
Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Beardmore St, Clydebank, Glasgow, G81 4HX United Kingdom
(Email: fraser.sutherland{at}gjnh.scot.nhs.uk).
It has been 7 years since Cribier [1] performed the first transcatheter aortic valve implantation in a human in 2002, and several more years since the original concept was floated by Andersen [2] in 1992. At the time, CoreValve was acquired by Medtronic Inc (Minneapolis, MN), the company claimed to have achieved in excess of 2,600 implants at 125 centers in 25 countries. Edwards Lifesciences (Irvine, CA) has had similar commercial success with their SAPIEN valve.
The target population for this technology is patients who are judged to be at high risk of death from conventional aortic valve replacement. In this regard, the authors [3] cite in-patient mortality in 5 patients (27.7%), which is similar to some of the early published series, but a little higher than the mortality quoted in more recent, "high-volume" Transcatheter Aortic Valve Implantation (TAVI) series presented at conferences. Admittedly, some of these latter studies only describe 30-day mortality, which masks some deaths and undoubtedly lowers the overall figure. Nevertheless, the authors are to be congratulated for their achievements in this difficult patient group.
The main focus of this article is the description of complications associated with TAVI. Thus far, the following complications have been described in the literature: malposition of prosthesis, intra-prosthetic insufficiency, paravalvar leakage, acute decompensation on the table, requiring massage or institution of extracorporeal support, stroke, obstruction of coronary ostia, aortic dissection, wire perforation of the ventricle, cardiac tamponade, urgent conversion to operative valve replacement, vascular access complications, including iliac injury requiring major vascular repair, perforation of the abdominal aorta, retroperitoneal bleeding secondary to iliac artery perforation, access site infection after complex vascular closure, lymphocele at access site, inadvertent hepatic puncture, heart block requiring permanent pacemaker implantation, new onset atrial fibrillation, late ventricular arrhythmia, myocardial infarction, respiratory failure, renal failure, multiorgan failure, and death. This paper's description of four new complications: acute mitral insufficiency, guide wire induced aortic insufficiency, haematoma of the septum with ventricular septal defect and left ventricular false aneurysm can now be added to the list. The list, per se, provides uncomfortable reading for anyone waiting for such a procedure. However, the reality is that many of these complications have now been addressed, and although they may not have been abolished altogether, their incidence or magnitude has reduced. Clearly, the first key step was recognition. Publication of complications can always invite criticism. However, this information is gratefully received by those of us interested in adopting TAVI in the near future. There is no doubt that it will prompt surgeons to find novel solutions or ways to avoid such complications.
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References
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- Cribier A, Eltchaninoff H, Bash A, et al. Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis: first human case description Circulation 2002;106:3006-3008.[Abstract/Free Full Text]
- Andersen HR, Knudsen LL, Hasenkam JM. Transluminal implantation of artificial heart valves: description of a new expandable aortic valve and initial results with implantation by catheter technique in closed chest pigs Eur Heart J 1992;13:704-708.[Abstract/Free Full Text]
- Al-Attar N, Ghodbane W, Himbert D, et al. Unexpected complications of transapical aortic valve implantation Ann Thorac Surg 2009;88:90-94.[Abstract/Free Full Text]
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