Complications of transcatheter aortic valve implantation (pp. 327-358)
Authors: (Roberto Lorusso, Sandro Gelsomino, Giuseppe De Cicco, Cesare Beghi§, Domenico Corradi, Pompilio Faggiano, Enrico Vizzardi, Antonio D’Aloia, Salvatore Curello, Claudia Fiorina, Giuliano Chizzola, Mario Frontini, Federica Ettori)
Abstract: Transcatheter aortic valve implantation (TAVI) is emerging as a valuable procedure to treat patients with severe aortic valve stenosis at high risk or not candidate for conventional aortic valve replacement. Besides obvious shortcomings related to the learning curve, adverse events do occur because of the inherent features of TAVI strictly linked to the application of the procedure as well as of the preoperative patient clinical profiles and comorbidities. These complications may profoundly affect procedural success rate as well as patient outcome at early and mid-term. Despite recent improvements due to advances in technological components as well as in transcatheter procedural management, several complications are still critical issues, and some may not be reduced by better device design or improved procedural strategies. Thorough awareness, therefore, of the prevalence and type of adverse events, potential predisposing factors or determinants, and management strategies to treat them once occurred, might be crucial to allow further improvement in patient outcome and reduce negative results, either in hospital or post discharge. This chapter will provide an overview about prevalence and features of TAVI complications, with particular emphasis on the impact on patient outcome and some insights about management as well as preventing strategies.
Since the first clinical procedure performed by Cribier in 2002 , an overwhelming number of clinical series of trans-catheter aortic valve implantation (TAVI) has been recorded (table). In a few years, remarkable advances in valve design and procedural management have been achieved, with substantial improvements in TAVI success rate. However, TAVI accounts for several technical and clinical challenges which may expose the patient at high risk for the occurrence of variable adverse events, some of them being potentially lethal. Complications in TAVI may account for several factors  which are inherently linked to the
procedure itself, namely advanced patient age, poor clinical conditions at treatment, and numerous and severe comorbidities to be faced intra or peri-procedurally, access and site of intervention, procedural management, last, but not least, type and extent of cardiovascular involvement. All these factors variably contribute to the occurrence and prognosis of TAVI complications, together with the kind of treatment applied to counteract such adverse events. Technical advances in instrument design and size, growing expertise, and refinement in patient selection and intra-procedural imaging, as well as careful peri-procedural management, are all factors supporting the ongoing progressive reduction in complication rate, enhancement in management, and increase in procedural success. Several misadventures, however, still occur during the procedure and appropriate recognition and treatment might lead to more favourable patient outcome, although careful planning and technical skill are paramount to prevent immediate or early untoward events. A comprehensive awareness and knowledge of complication profiles, therefore, are critical to prevent or limit untoward events.
The different types and prevalence of TAVI adverse events will be herein reviewed, the potential determinants or predisposing factors discussed, and the reported strategies to manage them described.