Keep percutaneous approach! Two cases of aortic annular rupture complicating trans catheter aortic valve implantation (TAVI) cured with a second prothesis implantation

Aortic annular rupture is one of the most dramatic complications in TAVI procedures. Emergency surgical treatment has a very high rate of mortality. In our series of 850 TAVI, this complication occurred in 7 cases, with three surgical deaths, one sudden death at day 15 and one less acute case with a spontaneous favourable evolution; the two last cases (occurred in 2018 and 2019) were managed differently. It was two female patients: 86 and 89 years old, with severe and symptomatic aortic stenosis. After discussion with our heart team, TAVI was selected because of age; a femoral access was validated and the aortic area was measured by CT-scan. The valve implantation success was very quickly followed by a severe collapsus, attributed, with cardiac echography, to a cardiac tamponnade. Percutaneous drainage with cell-saver was inefficient to stabilize clinical status. An angiography revealed a contrast extravasation at the level of inferior margin of the prothesis. We opted to a second Edwards Sapien 3 valve and a same size prothesis was implanted in both cases. Clinical amelioration was immediate and durable. The further evolution was uncomplicated. The two patients are still alive and asymptomatic at 24 and 18 months respectively ( Fig. 1 ). In case of annular rupture, probably due to prothesis oversizing (“between two”) or high amount of calcifications, where there is annular dilaceration rather than a clear perforation, surgery has a poor prognosis, because of technical challenges. It seems useful to visualize the annular tear. In our cases, a left ventriculography was very efficient to show it; therefore we decided another valve implantation in order to sealing the rupture. The double skirt of prothesis is probably more effective to cover the fissuration than a very challenging surgical sewing. Faced with this rare but killer complication, second prothesis with skirt could be the first choice, before calling for assistance our surgical colleagues.