Emergent Transcatheter Aortic Valve Replacement for the Treatment of Severe Aortic Stenosis Patients Presenting With Cardiogenic Shock or Cardiac Arrest; A Case Series

Background: Patients with severe aortic stenosis (AS) often present acutely with decompensated heart failure, cardiogenic shock or cardiac arrest requiring immediate intervention. Transcatheter aortic valve replacement (TAVR) has been effectively utilized to treat such patients. However, data on emergent TAVR remain scarce. Methods: We report a cases series of consecutive patients who underwent emergent TAVR between July 2016 and December 2017 at our institution. We describe the patients’ characteristics, the rational for intervention, procedural details, and mid-term outcomes. Results: Nine patients underwent emergent TAVR during the study’s period. Mean age was 80.6 ± 9.9, 44% were males, mean left ventricular ejection fraction was 42.8 ± 19.1. The rational for emergent intervention was cardiogenic shock in 6 (67%), cardiac arrest in 2 (22%), and both in 1 (11%). Mean transaortic valve gradient was 49.8 ± 20.4 mmHg. The mean time from event to TAVR time was 9.9 hours (range 2–14). Balloon aortic valvuloplasty was utilized pre-TAVR in four patients (44%), and peri-procedural percutaneous assist devices were used in three patients (33%). Sapien S3 was the most used valve (89%). Procedural success was achieved in 100%, and 8/9 patients (89%) survived to discharge. All surviving patients were alive and in class I/II New York Heart Association (NYHA) symptom category both at 1 month and a mean follow-up of 8.4 ± 3.7 months. Conclusions: TAVR may provide a feasible and effective treatment for patients with decompensated AS requiring emergent intervention. Further studies are needed to identify the optimal algorithm for the management of these patients.背景：重度主动脉瓣狭窄（aortic stenosis, AS）患者常急性起病，表现为失代偿性心力衰竭、心源性休克或心脏骤停，需立即接受临床干预。经导管主动脉瓣置换术（Transcatheter Aortic Valve Replacement, TAVR）已被成功应用于此类患者的治疗，但目前有关急诊TAVR的临床数据仍较为匮乏。方法：本研究纳入2016年7月至2017年12月期间于本机构接受急诊TAVR的连续性患者，构建病例系列研究。本研究详细描述了患者的临床特征、急诊干预的指征、手术操作细节以及中期随访结局。结果：研究周期内共计9例患者接受了急诊TAVR治疗。患者平均年龄为80.6±9.9岁，男性占比44%，平均左心室射血分数为42.8±19.1%。急诊干预的指征分别为：心源性休克6例（67%）、心脏骤停2例（22%），同时合并两种情况1例（11%）。平均跨主动脉瓣压力阶差为49.8±20.4 mmHg。从事件发作至实施TAVR的平均时间为9.9小时（范围2~14小时）。4例患者（44%）在TAVR术前接受了球囊主动脉瓣成形术，3例患者（33%）围手术期使用了经皮循环辅助装置。Sapien S3是最常使用的瓣膜型号（89%）。所有患者均实现手术成功，9例患者中有8例（89%）存活至出院。所有存活患者在术后1个月及平均8.4±3.7个月的随访周期内均存活，且纽约心脏协会（New York Heart Association, NYHA）心功能分级为I/II级。结论：对于需急诊干预的失代偿性AS患者，TAVR是一种可行且有效的治疗方案。未来仍需开展进一步研究，以明确此类患者的最佳临床管理流程。