Transapical Aortic Valve Implantation in 194 Patients: Problems, Complications, and Solutions

Abstract

Transapical aortic valve implantation is a novel approach for high-risk patients with severe aortic stenosis. During our learning curve, we were faced with several problems, technical difficulties, and complications, and our strategy and procedural technique evolved accordingly. We report our experience during the learning curve for establishing this new method. Between April 2008 and January 2010, 194 patients (mean age, 80 ± 9 years; range, 36 to 99 years) were treated by transapical aortic valve implantation. The mean Society of Thoracic Surgeons score was 23.5% ± 19.4% (range, 2.7% to 89.5%; logistic EuroSCORE, 41% ± 20%; range, 6% to 97%). We have established institutional guidelines on how to act in particular situations, with regard to patient selection, procedural steps, and complications concerning the procedure that have evolved according to our own experience. Mandatory angiographic visualization of the aortic root during valve deployment was introduced, combined with slow and gradual inflation of the balloon with possible correction of the valve position and its definitive position higher than we had been taught. Technical success was 99.5% with one conversion to conventional surgery (annulus rupture). One intraprocedural obstruction of the left coronary ostium was successfully treated by emergency stent implantation. The 30-day mortality was 5.7% for the whole group (11 of 194 patients), 3.8% for all patients without cardiogenic shock (7 of 182 patients), and 33% for the patients with cardiogenic shock (4 of 12 patients). There were 2 (1%) new clinical neurologic events postoperatively. A combination of patient-related evaluation and several small but precise technical modifications of the original transapical aortic valve implantation techniques reduced the rate of complications and increased success during the learning curve.