**10.3 Valve deployment**

Transcatheter heart valve malpositioning can occur due to lack of proper visualization or in inadequate ventricular pacing. Valve migration can also occur. Annular

rupture is a very rare, unpredictable, and life-threatening complication typically related to balloon aortic valvuloplasty or balloon-expandable valves.

#### **10.4 Aortic dissection**

Aortic dissection is a rare and possibly fatal complication of the procedure. Approximately 0.6–1.9% incidence rate has been shown after a TAVR procedure. Any part of the ascending or descending aorta can be involved in the dissection depending on which access approach was used. If post procedure an aortic dissection is suspected, aortic angiography can be used. The patient can have various symptoms and signs including chest pain, abdominal pain, and hypotension. It is important to note that the treatment of aortic dissection will vary based on the site and type of dissection. Type A dissections need to be treated with surgery while Type B can be medically managed [53].

#### **10.5 Organ injuries**

*Stroke and brain injury:* Stroke is a feared neurological complication to suffer from after a TAVR. Incidence of stroke is approximately 1.6% and can be a source of morbidity [54].

*Myocardial ischemia/injury:* Coronary obstruction may occur after a TAVR and can be treated with percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), or valve repositioning/retrieval.


*Acute kidney injury (AKI):* A significant amount of TAVR patients do suffer from renal insufficiency. AKI have been associated with a worse outcome and approximately 2.24% of patients required dialysis. A study titled the PROTECT-TAVI (PROphylactic effecT of furosEmide-induCed diuresis with matched isotonic intravenous hydraTion in Transcatheter Aortic Valve Implantation) had 112 patients undergoing TAVR who were randomly assigned to intravenous hydration with normal saline matched with urine output with diuresis (RenalGuard group) versus a control group of just normal saline. The study showed the rate of AKI was lower in the RenalGuard group than the control group [51, 55].

#### **10.6 Arrhythmic complications**

*High grade heart block:* Having a history of baseline conduction abnormalities (such as bundle branch blocks) have been a known risk factor for having a post-procedural pace maker (PPM) placed. It may also depend on the type of valve placed, Sapien vs. CoreValve. One study noted, that post TAVR, PPM was placed in 1.8–8.5% of patients who received the Sapien versus 19.1–42.5% of patients who received CoreValve [56].

*New onset atrial fibrillation (NOAF):* This is also commonly seen after a TAVR. In one study it was identified that 31.9% of patients had NOAF in a 46-hour time period postoperatively [57].

#### **10.7 Valve-in-valve implantation complications**

For patients with a failed bioprosthetic valve, the types of complications are similar to those patients with native aortic valve stenosis. However, coronary artery obstruction is more common and paravalvular regurgitation and PPM placement are less frequent [58].

Due to new transcatheter heart valves that now have external covering sealing skirts, these new devices have led to a lower rate of PVL from 8.3% of the firstgeneration device to 5.4% with the second-generation device and down to 3.4% with the third-generation device.
