Direct Transaortic CoreValve Implantation Through Right Minithoracotomy in Patients With Patent Coronary Grafts

Right anterior mini-thoracotomy direct aortic self-expanding trans-catheter aortic valve implantation: A single center experience

OBJECTIVE

Transcatheter aortic valve implantation (TAVI) has been designed to treat elderly patients with severe aortic stenosis at high risk for surgery. These patients are also often affected by severe iliac-femoral arteriopathy, rendering the trans-femoral approach unusable. We report our experience with the direct-aortic approach to treat these patients.

METHODS

From May 2008 to November 2013 two hundred and thirty-two patients (131 female, 56%) with severe symptomatic aortic stenosis and no reasonable surgical option due to excessive risk were evaluated for TAVI at our department. Of these patients, 202 were deemed eligible for TAVI. Of this group, 50 underwent CoreValve implantation by the direct aortic approach through a right anterior mini-thoracotmy (28 female, 56%), mean age 81.2±6.9. A combined team of cardiologists, cardiac surgeons with expertise in hybrid procedures, and anesthetists performed all the procedures.

RESULTS

Twenty-eight (56%) patients were female and 11 (22%) were redo at TAVI. We used a 23-mm CoreValve Evolute in 3 patients (6%), and the most used valve size was the 29mm in 46% of patients. Mean hemodynamic trans-aortic gradient was less than 5mmHg. The paravalvular regurgitation was ≤ grade 1 in 46 patients as assessed by peri-procedural transesophageal echocardiography (TEE). Seven patients (7/43, 16%) required a permanent pacemaker implantation; 30-day mortality was 6% (3 patients). Seven patients (14.8%) died during follow-up. Actuarial survival at 2years is 84.7±5.3%.

CONCLUSIONS

Transcatheter aortic valve implantation with the direct aortic approach is safe and feasible, offering a new attractive option to treat selected high-risk patients with severe aortic stenosis and peripheral vasculopathy, including those requiring a re-do procedure.

Sheathless transcatheter aortic valve implantation via the direct aortic approach

Transcatheter aortic valve replacement (TAVR) has become an accepted alternate treatment modality to surgical aortic valve replacement in high surgical risk patients. There remains, however, a subset of patients in whom safe delivery of a TAVR device cannot be achieved by the femoral or subclavian routes. In such cases the direct aortic or transapical routes can be used though this still requires suitable anatomy. We present the first reported case of a direct aortic TAVR using a sheathless technique in order to provide sufficient distance to safely deliver the prosthesis.

Transcatheter aortic valve replacement with CoreValve

The treatment of aortic stenosis in high-risk surgical patients is now possible by transcatheter aortic valve replacement. The CoreValve is a new transcatheter valve with a unique design expanding its application in patients with aortic stenosis. The CoreValve is just completing clinical trial in the United States and not yet available for commercial use in the United States but is widely used in Europe.

Direct aortic transcatheter valve implantation via mini-thoracotomy using the Medtronic CoreValve

Transcatheter aortic valve implantation using the Medtronic CoreValve is a well-established procedure. Although previously carried out only through the common femoral artery, today it is possible to perform the procedure through different arterial alternative access sites. A direct aortic approach through the ascending aorta could be carried out via a right anterior mini-thoracotomy in the second intercostal space. The pericardium is opened to expose the aorta. Two purse-string sutures are then placed on the ascending aorta and a standard retrograde CoreValve implantation is performed with the standard delivery system. Advantages, contraindications, surgical technique and results are discussed.

Alternative Access in Transcatheter Aortic Valve Implantation: Brachiocephalic Artery Access

Direct ascending aortic access is an accepted alternative approach for transcatheter aortic valve implantation (TAVI) that can be preferred in case of excessive atherosclerosis or small caliber of femoral and subclavian vessels or after previous coronary artery bypass grafting with a patent left internal mammary artery graft. However, not all patients are suitable for this direct aortic approach. In these patients, we now use direct access through the brachiocephalic artery. The direct brachiocephalic access can be obtained with or without partial upper sternotomy, depending on the anatomy, which should be evaluated by preprocedural angiographic computed tomography scan. During the procedure, the cerebral tissue oxygen saturation is continuously monitored. We treated two patients with severe aortic valve stenosis, classified as not suitable for surgical aortic valve replacement, by means of TAVI through the brachiocephalic artery. Both patients had excessive iliac atherosclerotic disease. One had patent left internal mammary artery and venous grafts after previous coronary artery bypass grafting so the femoral, direct aortic, nor left subclavian access was suitable; the other had a severely atheromatous and calcified aorta. No procedural or late complications were seen. If transfemoral, subclavian, and direct aortic accesses for TAVI are contraindicated, the direct brachiocephalic access seems to be a safe and feasible alternative.