Instituto de Ciencias del Corazón (ICICOR) Hospital Clínico Universitario de Valladolid Intra-cardiac shunts following TAVR Ignacio J. Amat-Santos, MD, PhD, FESC Interventional Cardiologist Valladolid, Spain

Dr. Amat-Santos Dr. Rojas Dr. Zunzunegui Dr. Rodés-Cabau Dr. San Román

Complications following TAVR TAVR is considered a less invasive treatment option • Specific periprocedural and late cardiac (5% to 61%) and non-cardiac (5% to 84%) complications may occur (1). • Several registries have addressed the most prevalent and worrisome complications post-TAVR, enabling a better understanding of how to predict and manage these situations: • annular rupture (2), coronary obstruction (3), cardiac tamponade (4), conduction disturbances (5), infective endocarditis (IE) (6), stroke (7). 1. 2. 3. 4. 5. 6. 7. Hamm CW, et al. Eur Heart J 2016 Barbanti Met al. Circulation 2013 Ribeiro HB, et al. J Am Coll Cardiol Intv 2013 Rezq A, et al. J Am Coll Cardiol Intv 2012 Urena M, et al. J Am Coll Cardiol 2012 Amat-Santos IJ, et al. J Am Coll Cardiol Intv 2015. Nombela-Franco L, et al. Circulation 2012

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Intra-cardiac shunts Intracardiac shunts (ICS) post-TAVR consists of an intracardiac fistulae that can occur immediatedly or delayed after TAVR procedure ICS may share mechanisms with other life-threatening post-TAVR complications, such as annular rupture This complication had been poorly described

Mechanism of ICS Potential aetiology (hypothesis) Mechanical compression of calcium Damage caused by sheaths / guidewires Infective endocarditis

A lni di Aortic Prosthes is st nt Aort c Prosth sis I I f me 9 pt (17.0 ) Aort c Prosth sis I I 30 pts (56.6%) § lsolat d n iv valv 7 p s (13 .2%), 1solat d prosthet ic valv 4 pts (7.5%}, nd combin d h TAVI-IE 2 p s (3.8%)

r10 o C rlo Co + Ventricular co J. Am 86 .5 66 Male 88 Male Ca ete· za ion a Car 10 6 r10 co J. Am o C rlo Co Baseline characterist'cs 'AVI procedure detail Journal Age Valve AR lnit'al (Year) (years) Gender type degree symptoms (months) Organism Case reported 75 Male Moderate NO 4 \wnh enuiermuli Rev sp Cardiol 2015 86 CorcValve 26 Mild 0.2 Staoh aureu Can J Car·d ol 20 4 72 CoreValve 26 .5 f nterococcu jaecali Eur Heart J 2014 J horac Cardiovasc 2009 84 Male 66 Male Moderate Moderate Yes 6 I Staph epidermidi, Cor\ nehw re,ium + Ventricular arrhythmia 3 Strep. am.;inosus J Thorac Cardiovasc 20()() 88 Male Moderate Ye

Mechanism of ICS Potential aetiology (hypothesis) Mechanical compression of calcium Damage caused by sheaths / guidewires Infective endocarditis

Aseptic ICS

Baseline characteristics. The first case was published in 2009 (22) and the last in 2016 3 cases with transapical fistulas 28 cases with aseptic intra-cardiac shunts

CALCIFICATION 14.3% prior chest wall radiation 39% coronary artery disease 10.7% porcelain aorta CALCIFICATION 42.8% severe aortic valve calcification (MDCT) 21.4% asymmetrical extension to the LVOT.

Procedural characteristics AVA: 0.5+0.5 cm2, mean gradient: 53+10 mmHg Balloon-expandable TAVR: 85.7% • TF: 60.7%, TA: 14.3%, TSc: 3.5% Post-TAVR moderate-severe AR: 1 pt Post-dilation: 14.3% (not hemodynamic deterioration) Concomitant TAVR-related Complication: 39.3%: AV block in 21.4% Cardiac arrest in 7.2% Cardiac tamponade in 7.2%.

Development of AICS 28 cases across 25 centers Heart failure (46.4%) Incidence ~ 0.5% Median time: 21 days (IQR: 7-30) Intraprocedural diagnosis: 12 patients (43%) Mechanism: prosthesis / balloon / introducer SYMPTOMS: Heart failure (46.4%) stroke (3.6%) Asymptomatic (50%) • Mean Qp/Qs: 1.8 + 0.6 (range: 1.3 to 3.1)

Location of AICS

Tear (black arrows) in the aortic subannular region between the noncoronary valve and the right coronary artery, near a calcium nodule (white arrows).

Management & Outcomes

Mark SD, et al. J Am Coll Cardiol Intv 2015.

Management & Outcomes All deaths in symptomatic patients (p = 0.020) More symptomatic if higher Qp/Qs (1.9+0.6 vs. 1.4+0.1)

Final comments Post-TAVR AICS are uncommon Symtomatic: High 30-day mortality if un-treated Symptomatic & High-risk: Percutaneous shunt closure with low-profile closure devices Asymptomatic ?? further evaluation if high Qp/Qs ratios