CathLabHub

CathLabHub complications toolkitcathlabhub.com/toolkit/tavr-annular-rupture-coronary-obstructionIn review, October 24, 2026

Recognize

The signs on the monitor, the image and the patient.

  • MonitorSudden hypotension during or right after balloon expandable deployment or post dilation (rupture), or with ST change and ventricular arrhythmia (obstruction) 12.
  • EchoA new pericardial effusion or a root hematoma (rupture); new left ventricular wall motion loss with no effusion (obstruction) 2.
  • ImageContrast in the root wall or the pericardium (rupture); a left main that no longer fills on root injection (obstruction) 2.
  • PatientPain, agitation or loss of consciousness in a sedated patient.
  • PatientRisk factors: area oversizing and heavy left ventricular outflow calcium for rupture; low coronary height, a narrow sinus and valve in valve for obstruction 12.

Act now

In the order the operator does them. The first three come first, whatever else is happening.

  1. Say what you see and call the heart team surgeon and anesthesia to the room now.
  2. Echo now (TEE or TTE) and a root injection: effusion points to rupture, wall motion loss to obstruction 2.
  3. Support the circulation: vasopressors, and CPR or venoarterial ECMO if it fails 3.
  4. Rupture with tamponade: pericardiocentesis with autotransfusion, reverse heparin, and surgery for an uncontained rupture 45.
  5. Rupture contained without tamponade: no further dilation; some contained root hematomas have been observed without surgery.
  6. Obstruction: wire the coronary through a guide and stent from the ostium out past the valve frame (chimney); surgery or ECMO if it fails 2.
  7. Self expanding valve not yet released: recapture or reposition may relieve an obstruction.
  8. Record the time of each event for the VARC-3 report 6.

Equipment

From the complications cart. Linked items open in the equipment directory.

Drugs

Adult doses as the cited source gives them. Check your formulary and the label.

Who to call

The escalation ladder, first call first.

  1. Heart team surgeon: at once for either event.
  2. Anesthesia: airway and hemodynamics.
  3. Echo: TEE or TTE in the room.
  4. Perfusion and ECMO team: for collapse that does not respond.
  5. Second interventionalist: to wire and stent the coronary.

The bailout step by step

Chimney stent for coronary obstruction after TAVR 29

  1. Support the circulation while you work; ECMO early if it fails.
  2. Engage the obstructed coronary with a guide through or around the valve frame.
  3. Wire the vessel; use a guide extension if the guide will not seat.
  4. Choose a stent long enough to reach from the coronary to above the displaced leaflet.
  5. Deploy it from inside the coronary out past the valve frame, flared toward the aorta.
  6. Check flow and wall motion; image the ostium if you can.
  7. Failure: surgery.

Prevent

  • CT planning: annulus area and perimeter, root and outflow calcium, coronary heights and sinus dimensions 12.
  • Avoid aggressive oversizing of balloon expandable valves in heavily calcified roots 1.
  • High obstruction risk: protect the coronary with a wire and an undeployed stent, plan intentional leaflet laceration (BASILICA), or choose surgery 9.
  • Have the surgeon and ECMO available for high risk anatomy.

After care and documentation

  • Echo for effusion and wall motion; ECG and troponin.
  • Report by VARC-3 definitions; enter the event in the TVT registry 6.
  • Debrief the heart team; disclose to the patient and family.

Practice

No emergency simulator case for these yet; the structural simulator in the app runs TAVR cases in which complications show only through their signs. Browse the case library.

References

  1. Barbanti M, Yang TH, Rodes Cabau J, et al. Anatomical and procedural features associated with aortic root rupture during balloon-expandable transcatheter aortic valve replacement. Circulation 2013;128:244-253.
  2. Ribeiro HB, Webb JG, Makkar RR, et al. Predictive factors, management, and clinical outcomes of coronary obstruction following transcatheter aortic valve implantation: insights from a large multicenter registry. J Am Coll Cardiol 2013;62:1552-1562.
  3. Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 28, Other complications: hypotension, radiation skin injury, contrast induced acute kidney injury.
  4. Holmes DR Jr, Nishimura R, Fountain R, Turi ZG. Iatrogenic pericardial effusion and tamponade in the percutaneous intracardiac intervention era. JACC Cardiovasc Interv 2009;2:705-717.
  5. Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 26, Perforation.
  6. VARC-3 Writing Committee: Genereux P, Piazza N, Alu MC, et al. Valve Academic Research Consortium 3: updated endpoint definitions for aortic valve clinical research. J Am Coll Cardiol 2021;77:2717-2746.
  7. Brilakis ES. Manual of Percutaneous Coronary Interventions: A Step-by-Step Approach. Academic Press, Elsevier; 2021. Chapter 3, Medications.
  8. Panchal AR, Bartos JA, Cabanas JG, et al. Part 3: adult basic and advanced life support. 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2020;142(suppl 2):S366-S468.
  9. Khan JM, Greenbaum AB, Babaliaros VC, et al. The BASILICA trial: prospective multicenter investigation of intentional leaflet laceration to prevent TAVR coronary obstruction. JACC Cardiovasc Interv 2019;12:1240-1252.

Educational reference for cath lab teams, not medical advice and not a standard of care. Your local policy, the device instructions for use and current guidelines govern. Verify every dose before use. Printed from cathlabhub.com/toolkit/tavr-annular-rupture-coronary-obstruction. First version, in clinical review: an interventional cardiologist is checking every card before it is final. Every number cites its source on the card.