Time to surgical bailout and mortality in complicated transcatheter aortic valve replacement

Surgical bailout during transcatheter aortic valve replacement (TAVR) is rare but highly critical. We evaluated the impact of hospital infrastructure, procedural setting, timing metrics, and haemodynamic stability on patients requiring emergent surgical bailout.

A single-centre analysis was conducted on consecutive TAVR cases requiring emergent surgical bailout between 2009 and 2024. Two eras were compared: Era 1 (2009-2016), with procedures performed in a conventional catheterisation laboratory (CCL) requiring transfer to a distant operating room, and Era 2 (2017-2024), using a purpose-built hybrid operating room (HOR) with all disciplines on site. The primary endpoint was in-hospital mortality. Secondary endpoints included time to extracorporeal life support (ECLS) initiation and surgical incision.

Of 3039 TAVR procedures, 16 patients (0.53%) required surgical bailout (10 in Era 1, 6 in Era 2). In-hospital mortality was 100% in the CCL group versus 33.3% in the HOR group (P < 0.01). While time to ECLS was similar, time to surgical intervention was significantly shorter in the HOR group. All HOR patients received definitive surgical treatment, whereas 60% of CCL patients died before surgery could be initiated. Haemodynamic instability prior to conversion differed significantly between groups.

Surgical bailout during TAVR is rare, but associated mortality remains high. Bailout performed in a HOR was associated with shorter delays to surgical incision and improved outcomes, with haemodynamic stability at the time of conversion emerging as an important factor associated with survival. These findings highlight the potential relevance of minimising time to surgery through optimised infrastructure, such as a HOR.