Aortic root rupture: implications of catheter-guided aortic valve replacement

Area of Science:

• Cardiovascular Surgery
• Interventional Cardiology
• Medical Device Technology

Background:

• Transcatheter aortic valve implantation (TAVI) is a well-established procedure for aortic valve replacement, particularly in high-risk patients.
• Its use is expanding, representing over 30% of isolated aortic valve replacements in some regions.
• Perioperative aortic root (AoR) rupture during TAVI is a rare but devastating complication with high mortality, with limited literature available.

Purpose of the Study:

• To review the pathophysiology of aortic root rupture during TAVI.
• To analyze the role of aortic root morphology in this complication.
• To highlight predictive factors for AoR rupture in TAVI procedures.

Main Methods:

• Literature review focusing on perioperative aortic root rupture in TAVI.
• Analysis of case reports and studies detailing AoR rupture during TAVI.
• Examination of the anatomical and procedural factors contributing to AoR rupture.

Main Results:

• Perioperative AoR rupture occurs in 0.5-1.5% of TAVI procedures, with nearly 100% mortality.
• Valve oversizing and balloon dilation in small or calcified aortic roots are identified as significant predictive factors.
• The anchoring substrate of the AoR to the left ventricle ostium is the most vulnerable structure.

Conclusions:

• The fragility of the AoR's anchoring substrate, unaffected by degenerative valve disease, predisposes it to rupture.
• TAVI and/or balloon dilation can cause lesions on this substrate due to calcium on valve leaflets.
• This can lead to catastrophic AoR rupture, emphasizing the need for careful patient selection and procedural technique.