Acquired Aseptic Intracardiac Shunts Following Transcatheter Aortic Valve Replacement: A Systematic Review

JACC Cardiovasc Interv. 2016 Dec 26;9(24):2527-2538. doi: 10.1016/j.jcin.2016.09.034. Epub 2016 Nov 23.

Abstract

Objectives: The aim of this study was to describe the incidence, mechanisms, features, and management of aseptic intracardiac shunts (AICS).

Background: AICS following transcatheter aortic valve replacement (TAVR) are an uncommon and barely described complication.

Methods: A systematic review was performed of all published cases of AICS following TAVR, and the incidence, predictors, main features, management, and related outcomes were analyzed.

Results: A total of 31 post-TAVR AICS were gathered. After excluding transapical fistulas, the 28 remaining cases corresponded with an incidence of about 0.5%. Mean age and mean logistic European System for Cardiac Operative Risk Evaluation score were 80 ± 11 years and 19.2 ± 8.3%, respectively. Prior radiation therapy for cancer was present in 14.3%, and 42.8% had severe calcification of the aortic valve. TAVR was undertaken using balloon-expandable prostheses in the majority of cases (85.7%), via the transapical approach in one-third. Median time from TAVR to diagnosis was 21 days (interquartile range: 7 to 30 days), with intraprocedural suspicion in 12 cases (42.9%) and a mean Qp/Qs ratio of 1.8 ± 0.6. The most common location for AICS was the interventricular septum (60.7%). Heart failure was frequent (46.4%), but 14 patients (50%) remained asymptomatic. Medical treatment (71.4%) was associated with poor outcomes (30-day mortality rate 25%), especially in symptomatic patients (35% vs. 0%; p = 0.020) and in those with higher Qp/Qs ratios (1.9 ± 0.6 vs. 1.4 ± 0.1), while cardiac surgery (3.6%), and percutaneous closure (25%) led to good outcomes after a median follow-up period of 3 months (interquartile range: 1 to 9 months).

Conclusions: Post-TAVR AICS are uncommon but have high 30-day mortality if left untreated, especially in symptomatic patients. Percutaneous closure was feasible and safe in symptomatic patients but remains controversial in asymptomatic subjects.

Keywords: TAVR; cardiac shunts; percutaneous closure devices.

Publication types

  • Review
  • Systematic Review

MeSH terms

  • Aged
  • Aged, 80 and over
  • Aortic Valve / physiopathology
  • Aortic Valve / surgery*
  • Aortic Valve Stenosis / physiopathology
  • Aortic Valve Stenosis / surgery*
  • Coronary Circulation*
  • Female
  • Heart Diseases / etiology*
  • Heart Diseases / mortality
  • Heart Diseases / physiopathology
  • Heart Diseases / therapy
  • Humans
  • Incidence
  • Male
  • Risk Factors
  • Time Factors
  • Transcatheter Aortic Valve Replacement / adverse effects*
  • Transcatheter Aortic Valve Replacement / mortality
  • Treatment Outcome