Direct Aortic Access for Transcatheter Self-Expanding Aortic Bioprosthetic Valves Implantation

Background. Transcatheter aortic valve implantation (TAVI) has been designed to treat elderly patients with severe aortic stenosis at high risk for operation; however, these patients are also often affected by severe iliac-femoral arteriopathy that prohibits the transfemoral approach. Methods. From May 2008 to January 2012, 400 patients were evaluated for TAVI at our center; of these, 141 patients (64 men; mean age 81.3 +/- 8 years) with severe symptomatic aortic stenosis and no reasonable surgical option due to excessive risk were eligible for CoreValve (137 patients; Medtronic Inc, MN) or Sapien (Edwards Lifesciences, CA) implantation. Twenty-five patients (all affected by severe peripheral vasculopathy, including five re-do procedures), with a mean The Society of Thoracic Surgeons mortality score 11% +/- 6%, underwent CoreValve implantation directly from the ascending aorta through a right anterior minithoracotomy. This case series was reviewed to evaluate the clinical outcomes of these patients. A combined team of cardiologists, cardiac surgeons with expertise in hybrid procedures, and anesthetists performed all the procedures. Results. In all patients after valve deployment, the mean aortic gradient immediately dropped to 5 mm Hg or less, and the angiographic grade aortic insufficiency was 1 or less in 22 patients. One patient was converted to the transfemoral approach due to an extremely fragile aortic wall, but the patient died of abdominal aorta aneurysm rupture on postoperative day 1. Procedural success was obtained in the remaining 24 patients. A left ventricle tear in 1 patient was successfully surgically treated. Four patients required a permanent pacemaker implantation. Thirty-day mortality was 8% (2 patients). All discharged patients improved their New York Heart Association functional class and functional capacity, and echocardiograms demonstrated good valve performance up to 2 years (mean valve gradient, 9 mm Hg). During follow-up, 1 patient died of cachexia and another of bone marrow aplasia. Conclusions. TAVI 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, and has emerged as a valuable alternative route to transapical access. (Ann Thorac Surg 2012;94:497-503) (c) 2012 by The Society of Thoracic Surgeons