Anatomical and Procedural Features Associated with Aortic Root Rupture During Balloon-Expandable Transcatheter Aortic Valve Replacement.

BACKGROUND: Aortic root rupture is a major concern with balloon expandable transcatheter aortic valve replacement (TAVR). We sought to identify predictors of aortic root rupture during balloon-expandable TAVR using multidetector computed tomography (MDCT). METHODS AND RESULTS: Thirty one consecutive patients who experienced left ventricular outflow tract (LVOT)/annular/aortic contained/non-contained rupture during TAVR were collected from 16 centers. A caliper-matched sample of 31 consecutive patients without annular rupture, who underwent pre-TAVR MDCT served as a control group. MDCT assessment included short and long axis diameters and cross sectional area of the sinotubular junction, annulus and LVOT, as well as the presence, location, and extent of calcification of the LVOT. There were no significant differences between the two groups in any preoperative clinical and echocardiographic variables. Aortic root rupture was identified in 20 patients and periaortic hematoma in 11. Patients with root rupture had a higher degree of subannular/LVOT calcification quantified by Agatston score (181.2±211.0 vs. 22.5±37.6, p<0.001), and a higher frequency of ≥20% annular area oversizing (79.4% vs. 29.0%, p<0.001) and balloon post-dilatation (22.6% vs. 0.0%, p=0.005). In conditional logistic regression analysis for the matched data, moderate/severe LVOT/subannular calcifications (Odds Ratio [OR]: 10.92, 95%Confidence Interval [CI]: 3.23 to 36.91, p<0.001) and prosthesis oversizing ≥20% (OR:8.38,95%CI: 2.67 to 26.33, p<0.001) were associated with aortic root contained/non-contained rupture. CONCLUSIONS: This study demonstrates that LVOT calcification and aggressive annular area oversizing are associated with an increased risk of aortic root rupture during TAVR with balloon-expandable prostheses. Larger studies are warranted to confirm these findings