1. VSD post TAVR: Mechanisms, Presentation and Management
Haim Danenberg, MD
Hadassah Hebrew University Medical Center
Jerusalem, Israel

2. Disclosure Statement of Financial Interest
I, [insert name], DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

3. Haim Danenberg, MD
Clinical proctor, Medtronic
Consultant, 3-D systems

4. Background
VSD may occur following trauma, cardiac surgery or post MI.
VSD is a rare complication of transcatheter aortic valve implantation (TAVI).

5. Background – VSD severity definition
Restrictive VSD
Size of the shunt: small (Qp/Qs ≤1.4:1)
Non significant left to right shunt (pulmonary-aortic systolic pressure of 0.3)
Moderately restrictive VSD
Size of shunt: moderate (Qp/Qs of 1.4 to 2.2)
Pulmonary-aortic systolic pressure ratio <
Large or nonrestrictive VSD
Size of shunt: large shunt (Qp/Qs >2.2)
Pulmonary-aortic systolic pressure ratio > 0.66.
Qp = Pulmonary flow
Qs = Systemic flow
Qp:Qs describes the magnitude of a cardiovascular shunt
Normally = 1:1
Left to right shunts >1.0
Right to left shunts <1.0

6. 31 patients: 86% balloon-expandable 17 VSD 7 aortic root-RV fistula
3 trans-apical fistula
2 LV-RA (Gerbode)
86% balloon-expandable
Estimated incidence 1.5%..
Rojas et al. JACC Int 2016

7. 18 VSD 2 LV-RA (Gerbode) Risk Factors: Severe annular calcification
Oversizing
Oval/assymetric annulus
Post dilatation
Ando et al. Heart, Lung and Circulation 2016

9. Clinical presentation / therapy
Time of diagnosis:
Procedure-one year (median 7days)
12 (75%) dyspnea-overt heart failure
4 (25%) asymptomatic
4 not reported
6 patients treated - percutaneous/surgical (1) closure
mVSD septal occluder

10. Study population
Three center, retrospective study of 400 patients who underwent TAVI in 2015.
Age (years)
81 (39-95)
Gender
Male
197
Female
203
Euroscore II
5.58 ± 5.76
Valve type
Sapien (XT/S3)
188
CoreValve (classic/evolut)
Other/none 15
30 day mortality 2%

11. Results
Six patients (1.5%) were subsequently diagnosed with a new VSD post-procedurally by transthoracic echocardiography.
All patients were hemodynamically stable with no clinical signs or symptoms.
No need for further intervention.

12. Severity of AV calcification
Post TAVR VSD patients
Pt.
Age
Gender
Severity of LVH
Severity of AV calcification
Device/
size
VSD Location
Severity of VSD
(mmHg, mm) 1 83 F
12 mm
Severe
XT 26
Membranous
Gradient = 140;
VSD < 2 mm 2 87
14 mm
CoreV 26
Minimal; Restrictive 3 82 M
13 mm
Moderate
S3 29
Gradient = 154
Qp/Qs 1.1;
VSD = 4 mm 4 81
12 mm 
Gradient = 64 5 79
11mm
Evolut 26
Muscular – near the apex
Gradient = 66.5 6 84
Gradient = 88;
VSD = 6 mm

13. Representative case: Membranous VSD

14. Representative case: Muscular VSD

15. Mechanism of Membranous VSD – Hypothesis
Overestimation of bioprosthetic valve size or highly calcific / narrow LVOT leading to high pressure exerted on the membranous part of the septum, potentially leading to its tearing and VSD formation.
Prevention:
Meticulous analysis of all imaging modalities enabling optimal choice of the most suitable valve and size.
Modeling / 3-D printing of valve apparatus?
Recommended height of implantation of the valve 33% below the sinuses during the final pacing run. Ideally 2-3 mm below the annulus. Hahn 2015 JACC

16. Mechanism of Muscular VSD – Hypothesis
Trauma to the interventricular septum caused by the stiff wire inserted to the left ventricle (in both of our cases Amplatz superstiff 1cm).
Increased risk in hypertrophic, hypercontractile (usually found in elderly women) left ventricle.
Prevention: Extreme caution in small ventricles, wire insertion via pigtail catheter and the use of a dedicated pre-shaped stiff wires (Confida/Safari) .

17. Post TAVR VSD: conclusions
VSD is a rare complication of TAVR with an incidence ranging %
Most VSDs are of no hemodynamic significance, probably underdiagnosed and call for no special therapy. Large, hemodynamic significant VSDs may warrant defect closure
To minimize the risk of VSD formation it is recommended to:
Perform meticulous evaluation of the aortic valve annulus and LVOT with special focus on calcium dispersion
Accurate positioning of the bioprosthetic valve
Proper pre-shaping of the stiff wire or use of a dedicated stiff wire & deployment of wire via pigtail catheter