The transapical approach for aortic valve implantation

Abstract

Percutaneous aortic valve implantation has been performed clinically in high-risk patients with severe aortic stenosis. Transfemoral retrograde valve delivery is limited by concomitant peripheral vascular disease and the size of the delivery system. We report on the alternative transapical approach that allows accurate antegrade placement of a catheter-deliverable aortic valve. Over a 2-year period, 26 consecutive patients (84.3 +/- 6.5 years) were treated at our center. Transapical aortic valve implantation was performed with 23-mm and 26-mm pericardial valves (Cribier-Edwards; Edwards Lifesciences, Irvine, Calif) mounted on a stainless steel stent. A limited anterolateral incision, in the fifth intercostal space, was used to access the apex of the heart. The valve was crimped, placed into a 24F sheath, and introduced into the left ventricle through purse-string sutures. Fluoroscopy and transesophageal echocardiography were used to guide the catheter across the native valve and to direct deployment of the stent at the level of the annulus. During deployment, the heart was unloaded with extracorporeal support or with rapid ventricular pacing. The average logistic EuroSCORE-predicted risk for mortality was 36.5% +/- 5.8%. All valves were successfully deployed at the target. On echocardiography, all valves showed good hemodynamic function with only minor paravalvular leakages. The mean transaortic valve gradient was 6 +/- 2 mm Hg. Thirty-day mortality was 15% (n = 4). One patient died of perforation of the right ventricle and 1 of dissection of the aortic root. There were 2 cases of conversion to open surgery. In 2 patients, the left main stem was partially obstructed by the native valve and required stent angioplasty. Initial results of the transapical approach are encouraging. Long-term studies and randomized protocols will be required to further evaluate this procedure.