1. 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

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

3. 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 Barbanti Met al. Circulation 2013
Ribeiro HB, et al. J Am Coll Cardiol Intv Rezq A, et al. J Am Coll Cardiol Intv Urena M, et al. J Am Coll Cardiol 2012
Amat-Santos IJ, et al. J Am Coll Cardiol Intv Nombela-Franco L, et al. Circulation 2012

6. 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

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

8. A lni di Aortic Prosthes is st nt Aort c Prosth sis I I f me
9 pt ( )
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%)

9. 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

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

11. Aseptic ICS

12. 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

15. 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.

16. Procedural characteristics
AVA: cm2, mean gradient: 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%.

17. 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: (range: 1.3 to 3.1)

18. Location of AICS

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

20. Management & Outcomes

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

23. Management & Outcomes
All deaths in symptomatic patients (p = 0.020) More symptomatic if higher Qp/Qs ( vs )

24. 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