What is the management and treatment of annular rupture?

Annular Rupture: Definition and Management

What is Annular Rupture?

Annular rupture is a rare but devastating complication of transcatheter aortic valve replacement (TAVR) involving injury to the aortic root and left ventricular outflow tract, with mortality rates approaching 50% when it occurs. 1

Annular rupture encompasses different procedural-related injuries classified by anatomical location into four main types: supra-annular, intra-annular, subannular, and combined rupture 2. This complication typically manifests as sudden cardiac tamponade with hemodynamic collapse during or immediately after valve deployment 1, 3.

Risk Factors for Annular Rupture

Patient-Related Risk Factors

• Female sex 1
• Smaller annular size (particularly <21 mm) 1
• Small sinotubular junction 1
• Prior radiation therapy 1
• Porcelain aorta 1

Anatomic Risk Factors

• Bulky and dense calcification, particularly moderate-to-severe sub-annular calcification 1
• Protruding landing zone calcification below the non-coronary cusp is most closely associated with annular injury 1, 4
• Depth of calcification within the LVOT, especially calcification extending >1 mm into the lumen 4

Procedural Risk Factors

• Use of balloon-expandable valves (higher radial force) 1
• Aggressive balloon predilation 1
• Significant prosthesis oversizing, particularly when combined with protruding calcification 1, 4

Management Algorithm

Immediate Recognition and Stabilization

The key to survival is immediate recognition through hemodynamic monitoring and echocardiographic surveillance, followed by rapid escalation of therapy based on bleeding severity. 1, 3

Step 1: Identify Hemodynamic Instability

• Monitor for sudden hypotension during or immediately after valve deployment 3
• Maintain high index of suspicion in high-risk patients (female, heavy calcification, aggressive oversizing) 1

Step 2: Confirm Diagnosis

• Perform immediate echocardiography (TEE or TTE) to identify pericardial effusion and tamponade 1, 3
• Aortic root angiography can confirm contrast extravasation 3

Treatment Approach Based on Severity

Management options range from comfort care in moribund patients to emergent surgical conversion, with the choice depending on bleeding severity, hemodynamic stability, and surgical candidacy. 1

For Smaller, Contained Leaks:

• Emergent pericardiocentesis to relieve tamponade 1, 3
• Pericardial drainage with autotransfusion 1
• Placement of pericardial drain for ongoing evacuation 3
• Injection of hemostatic agents (e.g., SURGIFLO) into pericardial space 3
• Repeat aortogram to confirm cessation of extravasation 3
• Coil embolization at the rupture site has been reported as successful percutaneous alternative 5

For Ongoing Hemorrhage or Hemodynamic Instability:

• Emergent conversion to open surgical repair with pericardial patching of the defect 1, 3, 6
• Extracorporeal membrane oxygenation (ECMO) support may be necessary for cardiac arrest or severe hemodynamic compromise 6
• Delayed chest closure (post-op day 2) may be required for ongoing bleeding 3

For Moribund Patients:

• Comfort care and sedation when no other viable options exist 1

Prevention Strategies

Prevention through meticulous pre-procedural CT planning and appropriate valve selection is paramount given the high mortality of this complication. 1, 4

Pre-Procedural CT Assessment

• Mandatory gated cardiac CT with multiphasic reconstruction to identify systolic phase with largest annular dimensions 4
• Qualitative grading of LVOT calcification as none, mild, moderate, or severe based on depth, morphology, and location 1, 4
• Document specific location of protruding calcification, especially below the non-coronary cusp 1, 4
• CT-based area and perimeter measurements are mandatory over 2D echocardiographic measurements alone 4

Valve Selection and Sizing

• Reduce degree of oversizing in patients with moderate-to-severe subannular calcification, particularly protruding nodules 1, 4
• Consider self-expandable valves in high-risk anatomy, as they exert lower radial force than balloon-expandable valves 4
• Avoid aggressive balloon predilation in heavily calcified annuli 1

High-Risk Scenarios Requiring Special Consideration

• Protruding nodules below the non-coronary cusp carry the highest rupture risk and warrant reduced oversizing or valve platform change 1, 4
• Female patients with small annuli (<21 mm) and heavy calcification represent the highest-risk cohort 1, 4

Common Pitfalls

• Undersizing the valve due to reliance on 2D echo measurements leads to paravalvular regurgitation; always use CT-based area/perimeter 4
• Aggressive oversizing in the presence of protruding LVOT calcification dramatically increases annular rupture risk 4
• Failing to document the specific location of protruding calcification prevents informed valve selection and risk stratification 4
• Delayed recognition of tamponade due to inadequate echocardiographic monitoring during and immediately after deployment 3