Unruptured Thoracic Aneurysm in TAVR Tied to Aortic Dissection, Cardiac Tamponade

In the small percentage of patients undergoing TAVR who have a preexisting unruptured thoracic aortic aneurysm (TAA), there appears to be increased risks of both aortic dissection and cardiac tamponade, according to a nationwide analysis.

“It is very important to know what will happen to these patients if you just replace the aortic valve and leave other things alone,” senior author Samir R. Kapadia, MD (Cleveland Clinic Foundation, Ohio), told TCTMD. Patients with a TAA did not have more post-TAVR complications than those without the condition, and TAA had no significant impact on in-hospital mortality, stroke, MI, or bleeding. Even so, these cases need careful consideration by the heart team, the researchers say.

“We think that it should be brought to people's awareness that if you have thoracic aortic aneurysm, you should consider surgery as the first choice,” Kapadia said. While every patient is different and treatment should be individualized, there should at least be a discussion with the patient about the potential for dissection and cardiac tamponade following TAVR, he added.

Aortic Dissection Doubled

Published August 13, 2020, in Catheterization and Cardiovascular Interventions, the observational study included 171,011 TAVR patients treated between January 2012 and December 2017. Of those, 1% had a concomitant unruptured TAA. They were more likely than those without a TAA to be younger, and to have atherosclerosis and bicuspid aortic valves.

There were no differences between the TAA and non-TAA groups for in-hospital death, stroke, acute MI, or blood transfusion. However, cardiac tamponade occurred in 1.4% of TAA patients versus 0.9% of those without TAA (P = 0.047) and aortic dissection occurred in 1% versus 0.4% (P = 0.001). After exclusion of patients with bicuspid valves, patients with TAA still had higher rates of aortic dissection than those without TAA (1.1% vs 0.4%; P < 0.001), as well as a marginally insignificant increased risk of cardiac tamponade (1.4% vs 0.9%; P = 0.051).

Regardless of the presence of TAA, nearly one-quarter of patients who developed cardiac tamponade or aortic dissection after TAVR died.

Multivariate logistic regression analysis confirmed that the presence of unruptured TAA was associated with more post-TAVR aortic dissection (OR 2.11; 95% CI 1.30-3.43) and cardiac tamponade (OR 1.68; 95% CI 1.10-2.57). The analysis also confirmed that in addition to TAA, female sex and presence of atherosclerosis predicted aortic dissection, while female sex and bicuspid aortic valve were linked to cardiac tamponade.

According to the researchers, it is not clear why patients did not undergo surgery to address both the AVR and the TAA. “This may have been related to patients’ comorbidities or possibly determined by the heart team that these aneurysms did not require surgical correction,” they write. Since the database does not include information on individual surgical risk, they say, “it is conceivable that the overwhelming majority of included TAVR patients were deemed inoperable or high surgical risk, as opposed to intermediate- or low-risk, owing to their age, sheer burden of comorbidities, as well as the indicated use of TAVR at the time of the study period.”

To TCTMD, Kapadia pointed out that the database also does not contain information on device sizes, whether TAAs were ascending or descending, and other aspects of the TAAs, making it impossible to know if longer devices may have increased the risk of dissection in some patients.

Commenting on the study for TCTMD, Ashish Pershad, MD (Banner - University Medicine Heart Institute, Phoenix, AZ), wasn’t completely sold on the new findings. He cautioned against drawing strong conclusions from the analysis, which was based on patients in the Nationwide Readmissions Database.

“I feel like a more reasonable assumption from this would be that there might be a signal that requires further investigation in a more organized fashion, either in a randomized trial or a patient-level study,” he noted.

Nonetheless, Pershad agreed with Kapadia and colleagues that patient-specific discussions are crucial in this population. “We assess the patient's risk and present both options,” he said. “Some patients are going to be willing to accept a slightly higher risk of the TAVR and are okay with it because the outcomes are not bad after the valve deployment. This is a very individualized decision.”

Photo Credit: Abugov S. Case 4: percutaneous repair of thoracic aortic aneurysms. Presented at: TCT 2012. October 22, 2012. Miami, FL.