Efficacy of emergency room approach versus emergency medical services approach for STEMI activation strategy: optimizing hospital resource utilization while maintaining door-to-balloon time and mortality

Abstract

Background: Patients with severe aortic stenosis (AS) and prior cardiac surgery undergoing aortic valve replacement (AVR) are at high risk. We aimed to describe the fluoroscopy and left anterior descending (LAD) artery angiography guidance technique for transapical AVR access and the related procedural results. Methods: Patients with severe AS and prior cardiac surgery undergoing transapical AVR using LAD-angiographic guided apical puncture were analyzed (n=9). Additional guidance was added to the standard technique as follows. Mini-thoracotomy was performed at the level of the intercostal space in closer relationship to the apex identified by fluoroscopy. LAD angiography was performed at the time that the area of interest was recognized by radiopaque mark to ensure puncture lateral to the LAD (Fig. 1). Apical needle puncture was performed under fluoroscopy guidance directed towards the aortic root. Results: The population had a mean age of 83 years and were more frequently male (89%) with a high-risk profile (mean STS score of 11%). Two patients received the 23-mm Sapien valve, and seven patients received the 26-mm Sapien device. All nine patients underwent successful implantation of transcatheter aortic valves with virtual abolishment of transaortic gradient, without procedural complications. Conclusion: Fluoroscopy and angiography for guidance of transapical approach facilitate a safe and rapid access to the apex, ensuring no risk of damage to the LAD or large diagonals.