Transaortic Approach Research Articles

Combined Transcatheter Aortic Valve Replacement and Endovascular Aortic Repair: A Transfemoral Approach Dilemma

We report a case of an elderly patient with severe aortic stenosis (AS) too risky for conventional surgery because of comorbidities that included an infrarenal saccular abdominal aortic aneurysm (AAA). The presence of the aneurysm could impact the outcome of transcatheter aortic valve replacement (TAVR) as improved systolic pressure could increase the risk of aneurysm rupture. Transapical and transaortic approaches for TAVR precluded simultaneous endovascular aortic repair (EVAR). Transfemoral approach was the most viable option. Doing EVAR first would circumvent aortic rupture but it could be technically precarious to do EVAR before TAVR when both are done transfemorally. Contrast-induced nephropathy could be considered whether combined procedure is riskier than angiogram-dependent procedures performed in two settings. The patient underwent uncomplicated transfemoral TAVR and then EVAR in one setting. This case underscores the management strategy of a patient with this complicated clinical presentation and underlying pathologies in the light of presently available technologies.

ALTERNATIVE APPROACHES IN TAVR PROCEDURES FOR HIGH-RISK AND NON-OPERABLE PATIENTS

ALTERNATIVE APPROACHES IN TAVR PROCEDURES FOR HIGH-RISK AND NON-OPERABLE PATIENTS

USE OF ST. JUDE MEDICAL PORTICO VALVE: THE CANADIAN EXPERIENCE

Transcatheter aortic valve implantation (TAVI) is an alternative treatment to surgical aortic valve replacement in patients with severe aortic stenosis who are high-risk surgical candidates. While results following this technique have continued to improve, technical challenges remain in terms of avoiding paravalvular leaks, conduction abnormalities requiring pacemaker and coronary perfusion compromise. These common complications may potentially be reduced by a valve that is self expanding, resheathable and recapturable. The Portico Valve (St. Jude Medical, Minneapolis, Minnesota) fulfills these objectives in that it permits recapture and repositioning at up to 80% deployment. The objective of this study was to describe procedural outcomes in the first Canadian series of patients who underwent TAVI with the Portico Valve. The Portico Valve was implanted in 25 consecutive patients with severe aortic stenosis at 2 institutions using trans-femoral, trans-axillary or trans-aortic approaches. Patients underwent transthoracic echocardiography before and after TAVI. Clinical outcomes were evaluated at 6 weeks following surgery. Average age was 80.2 yrs ±7.3 yrs and 72.0% (n=18) of patients were female. Preoperative echocardiographic evaluation showed a mean aortic valve area of 0.7cm2 ±0.4cm2, aortic valve gradient of 43.4mmHg ±21.1mmHg, and an ejection fraction of 52.7% ±16%. Device implantation was successful in all patients. Access was obtained via the femoral artery in 19 patients (76%), the axillary artery in 4 patients (16%), and trans-aortically in 2 patients (8%). Valve recapture and repositioning took place in 9 (36%) patients, 4 (16%) of whom required recapturing and repositioning twice. Following implantation of the Portico Valve, mean aortic gradients were 8.8mmHg ±4.5mmHg. Additionally, 9 patients (36%) had no paravavlular leaks, while 6 (24%) had trivial, 7 (36%) had mild, and 3 (12%) had moderate paravalvular leaks. One patient (4%) required a pacemaker insertion. No patients suffered a peri-operative myocardial infarction. Of the 19 patients who had 6 week follow up, 3 (16%) required readmission and all were alive. We report the first Canadian series of successful implantation of the Portico Valve in patients requiring TAVI. The innovative feature that allows this valve to be recaptured and repositioned was used in nearly one third of patients, resulting in adequate positioning in all patients with low rates of aortic insufficiency and pacemaker requirements. Further research will be needed to compare the Portico valve to other TAVI valves with regards to clinical outcomes.

En bloc aortic and mitral valve replacement and left ventricular outflow tract enlargement using a combined transaortic and trans-septal atrial approach.

Aortic and mitral valve replacement with division and reconstruction of the inter-valvular fibrous body has been described in clinical situations involving infective endocarditis, extensive annular calcifications and diminutive valve annuli. Herein, we describe a combined transaortic and trans-septal approach with division of the inter-valvular fibrosa for combined aortic and mitral valve replacement. The reconstruction of the inter-valvular fibrous body, atrial walls and aortic root was carried out using a 'three-patch' technique with bovine pericardium.

Neurotransmission to parasympathetic cardiac vagal neurons in the brain stem is altered with left ventricular hypertrophy-induced heart failure.

Hypertension, cardiac hypertrophy, and heart failure (HF) are widespread and debilitating cardiovascular diseases that affect nearly 23 million people worldwide. A distinctive hallmark of these cardiovascular diseases is autonomic imbalance, with increased sympathetic activity and decreased parasympathetic vagal tone. Recent device-based approaches, such as implantable vagal stimulators that stimulate a multitude of visceral sensory and motor fibers in the vagus nerve, are being evaluated as new therapeutic approaches for these and other diseases. However, little is known about how parasympathetic activity to the heart is altered with these diseases, and this lack of knowledge is an obstacle in the goal of devising selective interventions that can target and selectively restore parasympathetic activity to the heart. To identify the changes that occur within the brain stem to diminish the parasympathetic cardiac activity, left ventricular hypertrophy was elicited in rats by aortic pressure overload using a transaortic constriction approach. Cardiac vagal neurons (CVNs) in the brain stem that generate parasympathetic activity to the heart were identified with a retrograde tracer and studied using patch-clamp electrophysiological recordings in vitro. Animals with left cardiac hypertrophy had diminished excitation of CVNs, which was mediated both by an augmented frequency of spontaneous inhibitory GABAergic neurotransmission (with no alteration of inhibitory glycinergic activity) as well as a diminished amplitude and frequency of excitatory neurotransmission to CVNs. Opportunities to alter these network pathways and neurotransmitter receptors provide future targets of intervention in the goal to restore parasympathetic activity and autonomic balance to the heart in cardiac hypertrophy and other cardiovascular diseases.

Outcomes of Patients With Severe Chronic Lung Disease Who Are Undergoing Transcatheter Aortic Valve Replacement

In this study, we sought to determine the clinical outcomes after transcatheter aortic valve replacement (TAVR) among patients with chronic lung disease (CLD) and to evaluate the safety of transaortic versus transapical alternate access approaches in patients with varying severities of CLD. Clinical records for patients undergoing TAVR from 2011 to 2014 in The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry were linked to Medicare hospital claims (n = 11,656). Clinical outcomes were evaluated across strata of CLD severity, and the risk-adjusted association between access route and post-TAVR mortality was determined among patients with severe CLD. In this cohort (median age, 84 years; 51.7% female), moderate to severe CLD was present in 27.7% (14.3%, moderate; 13.4%, severe). Compared with patients with no or mild CLD, patients with severe CLD had a higher rate of post-TAVR mortality to 1-year (32.3% versus 21.0%; adjusted hazard ratio [HR], 1.48; 95% confidence interval [CI], 1.31 to 1.66), as did those with moderate CLD (25.5%; adjusted HR, 1.16; 95% CI, 1.03 to 1.30). The adjusted rate of mortality was similar for transapical versus transaortic approaches to 1 year (adjusted HR, 1.17; 95% CI, 0.83 to 1.65). Moderate or severe CLD is associated with an increased risk of death to 1-year after TAVR, and among patients with severe CLD, the risk of death appears to be similar with either transapical or transaortic alternate-access approaches. Further study is necessary to understand strategies to mitigate risk associated with CLD and the long-term implications of these findings.

Catheter ablation of idiopathic fascicular ventricular tachycardia: The role of isolated diastolic potentials during mapping in sinus rhythm

Article history: Received 15 July 2015 Accepted 1 August 2015 Available online 3 August 2015 3.5 mm irrigated-tip catheter (NaviStar or SmartTouch Thermocool, BiosenseWebster) was used for mapping and ablation. The electroanatomic mapping of the left ventricle was performed using a threedimensional non-fluoroscopic mapping system (CARTO XP and CARTO 3, BiosenseWebster) via a retrograde transaortic approach. Intravenous heparin was administered throughout the procedure, targeting an activated clotting time around 300 s. A detailed substrate mapping during

Invited Commentary

Imagination is more important than knowledge. For knowledge is limited, whereas imagination embraces the entire world.–Albert Einstein, 1929 While Einstein wanted to describe imagination as the driving force behind the search for knowledge, the widespread use of a transcatheter aortic valve replacement (TAVR) is an example for the replacement of knowledge by imagination. It is quite astonishing that a novel technique like TAVR with at first a non-inferiority status [1Smith C.R. Leon M.B. Mack M.J. et al.Transcatheter versus Surgical Aortic-Valve Replacement in High-Risk Patients.N Engl J Med. 2011; 364: 2187-2198Crossref PubMed Scopus (4768) Google Scholar] over the established methods, shown in only 1 prospective randomized trial (by the way, sponsored by the same company selling the novel devices) with a very limited number of participants, could gain such relevance in patient treatment as well as in the scientific discussion. The superiority [2Adams D.H. Popma J.J. Reardon M.J. et al.Transcatheter aortic-valve replacement with a self-expanding prosthesis.N Engl J Med. 2014; 370: 1790-1798Crossref PubMed Scopus (2023) Google Scholar] of TAVR over conventional AVR could only later be shown in an, again, company-sponsored trial. The paper of Ribeiro and colleagues [3Ribeiro H. Dahou A. Urena M. et al.Myocardial injury after transaortic versus transapical transcatheter aortic valve replacement.Ann Thorac Surg. 2015; 99: 2001-2009Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar] deals with 2 different TAVR techniques (transaortic versus transapical approach) regarding myocardial injury and ventricular function after the procedure. A clear message can be read between the lines, although very cautiously phrased: transaortic (TAO) TAVR is superior to transapical (TA) TAVR because TAO TAVR leads to less myocardial injury and to a better left ventricular recovery. Interestingly, this does not lead to better clinical outcomes after 30 days or 12 months in the TAO TAVR group, as one would expect knowing the influence of high cardiac biomarkers on long-term outcomes after valve surgery [4Paparella D. Guida P. Caparrotti S. et al.Myocardial damage influences short- and mid-term survival after valve surgery: a prospective multicenter study.J Thorac Cardiovasc Surg. 2014; 148: 2373-2379Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar]. One important detail to be found in Supplemental Table 3 is not mentioned by the authors. Moderate or severe aortic valve regurgitation occurs nearly 4 times more often (nearly significantly more often) in the TAO TAVR group. Although there are data available on how high-degree aortic regurgitation worsens long-term survival [5Abdel-Wahab M. Zahn R. Horack M. et al.Aortic regurgitation after transcatheter aortic valve implantation: incidence and early outcome. Results from the German transcatheter aortic valve interventions registry.Heart. 2011; 97: 899-906Crossref PubMed Scopus (440) Google Scholar], the clinical outcomes of the 2 patient groups in this study are similar. Is it possible that higher biomarkers in the TA TAVR group and more aortic regurgitation in the TAO TAVR group balance each other? Clearly, the hypotheses of Ribeiro and colleagues [3Ribeiro H. Dahou A. Urena M. et al.Myocardial injury after transaortic versus transapical transcatheter aortic valve replacement.Ann Thorac Surg. 2015; 99: 2001-2009Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar] have to be proven “by future studies with larger sample size … to determine whether or not differences in myocardial injury … translate into significant differences in mortality…”, as the authors state themselves. Ribeiro and colleagues are to be congratulated on an excellent study inspired by their imagination, but they still have to contribute to the “limited knowledge.” Einstein again: “It’s important to go on asking questions.” Myocardial Injury After Transaortic Versus Transapical Transcatheter Aortic Valve ReplacementThe Annals of Thoracic SurgeryVol. 99Issue 6PreviewThe release of cardiac biomarkers of myocardial injury after transcatheter aortic valve replacement (TAVR) is common, but no data exist on patients undergoing TAVR through a transaortic approach. We aimed to evaluate the incidence and prognostic significance of the increase in cardiac biomarkers in nontransfemoral TAVR candidates, comparing transaortic and transapical approaches. Full-Text PDF

Myocardial Injury After Transaortic Versus Transapical Transcatheter Aortic Valve Replacement

The release of cardiac biomarkers of myocardial injury after transcatheter aortic valve replacement (TAVR) is common, but no data exist on patients undergoing TAVR through a transaortic approach. We aimed to evaluate the incidence and prognostic significance of the increase in cardiac biomarkers in nontransfemoral TAVR candidates, comparing transaortic and transapical approaches. After excluding patients deemed suitable for transfemoral TAVR, 251 consecutive patients (transaortic, 45; transapical, 206) were prospectively evaluated. Creatine kinase-myocardial band and cardiac troponin T levels were measured at baseline and at 6, 12, 24, 48, and 72 hours after TAVR. Baseline and 6- to 12-month echocardiographic and clinical follow-up were performed. After TAVR, cardiac troponin T increased above the upper normal values in all patients (peak value 0.64 μg/L [IQR, 0.39 to 1.03 μg/L]), whereas creatine kinase-myocardial band levels increased in 88% of patients (transaortic 51%, transapical 96%, p < 0.001; peak value 20.1μg/L [interquartile range, 14.3 to 31.6 μg/L]). Compared with the transaortic approach, the transapical approach was associated with a greater rise in both cardiac biomarkers (p < 0.001 for both), and a lesser improvement in left ventricular ejection fraction (p= 0.058) and global longitudinal strain (p= 0.039) at 6- to 12-month follow-up. Greater increases of cardiac troponin T levels were independently associated with 30-day and 1-year overall and cardiovascular mortality (p < 0.001 for all). A 15-fold rise in cardiac troponin T levels was the optimal threshold for determining poorer outcomes (p < 0.001). Periprocedural TAVR-related myocardial injury in nontransfemoral candidates was demonstrated in all patients, but the transapical approach was associated with significantly greater myocardial injury compared with the transaortic approach. A higher degree of myocardial injury translated into reduced left ventricular function improvement and lower early and midterm survival rates.

Direct Aortic Transcatheter Aortic Valve Implantation: Anaesthesia Attentions

Surgical replacement of aortic valve is the gold standard therapy for severe aortic valve stenosis. Transcatheter Aortic Valve Implantation (TAVI) is less invasive and becomes an alternative therapy reserved for patients with high operative risk. TAVI can be performed via transfemoral, transapical or transaortic approach. Patients with diseased or difficult femoral/iliac vascular access, poor left ventricular function and significant respiratory disease are not suitable for transfemoral or transapical approach. In this scenario, direct transaortic approach of TAVI is a feasible option. This case report presents a case of a 76-year-old man with symptomatic severe aortic valve stenosis who underwent general anaesthesia and was successfully treated by direct transaortic TAVI using Edwards Sapien XT aortic bioprosthesis.

Long-term outcomes associated with the transaortic approach to transcatheter Aortic valve replacement.

We investigated the long-term safety, efficacy and clinical outcomes associated with transaortic (TAO) transcatheter aortic valve replacement (TAVR) in the United States. We previously reported the technical feasibility and short-term safety of TAO TAVR. Compared to transapical (TAP) access, the TAO approach was associated with shorter median intensive care unit (ICU) length of stay (LOS) and more favorable technical learning curve. However, outcomes data beyond 30 days were lacking and the longer-term clinical consequences of this strategy were unknown. Mortality outcomes at 1 year (and longer) of 44 consecutive patients who underwent TAO TAVR in our institution were compared with that of 76 consecutive patients who underwent TAP TAVR at our site. Risk-adjusted analysis was performed in propensity-matched patients (25 from each group) to account for baseline differences. TAO TAVR was associated with a trend towards lower all-cause mortality at 1 year compared to TAP TAVR (18% vs. 34%, P=0.09 in the overall sample; 12% vs. 40%, P=0.05 in the matched cohort). The higher probability of survival with TAO TAVR persisted after a median follow-up period of 23 months (hazard ratio [HR]=1.96, P=0.06 in the overall sample; HR=3.4, P=0.01 in the matched cohort). Cardiovascular mortality at 1 year was lower with TAO TAVR (2% vs. 22%, P=0.01 in the overall sample; 4% vs. 28%, P=0.05 in the matched cohort). ICU LOS (shorter in the TAO group) and implantation of second prosthetic valve (higher incidence in the TAP group) were independent predictors of long-term mortality. The outcomes associated with TAO TAVR compare favorably with TAP TAVR. Our results appear to corroborate the long-term safety and efficacy of the TAO approach in TAVR patients with inadequate iliofemoral access.

Suprasternal direct aortic approach transcatheter aortic valve replacement avoids sternotomy and thoracotomy: first-in-man experience†.

Direct aortic deployment of a transcatheter aortic valve eliminates the need to traverse the aortic arch with the valve delivery system, enables placement of large sheaths in the aorta and innominate artery, provides maximal precision during deployment and ensures a safe, conventional surgical aortotomy closure. We describe the initial experience with the Suprasternal Aortic Access System (SuprAA System, Aegis Surgical Ltd, Dublin, Ireland) for direct transaortic/innominate valve delivery. Patients with severe, symptomatic aortic stenosis who were candidates for transcatheter aortic valve replacement (TAVR) via a direct transaortic approach were enrolled in the SuprAA-TAVR First-in-Man Study. Under general anaesthesia, the innominate artery and aortic arch were exposed in each patient, using the SuprAA System via a 2.5-cm incision directly above the sternal notch. The TAVR delivery sheath was positioned and the transcatheter valve deployed routinely under fluoroscopic guidance. Upon sheath removal, haemostasis at the aortotomy site was confidently secured using a double purse-string suture closure. All were extubated immediately. A meta-analysis of the direct aortic approach was done for comparison. Four male patients (mean 82.5 years) underwent SuprAA-TAVR (2 CoreValve; 2 SAPIEN). Anatomical visualization was excellent and suprasternal valve deployment was accurate regardless of sheath size with 100% Valve Academic Research Consortium-2 procedural success. The average total procedure time was 109.5 min without perioperative wound or vascular complications. The SuprAA System provides direct aortic/innominate access without sternal or thoracotomy incision. Patient recovery to normal activity is maximized, sheath size limitations are eliminated and valve deployment is precise. This innovative system creates a new and exciting minimally invasive approach for high-risk patients with aortic stenosis.

Surgery for hypertrophic cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is a genetically determined cardiac disease characterised by otherwise unexplained myocardial hypertrophy of the left ventricle, and may result in left ventricular outflow tract obstruction. It is the most common cause of sudden cardiac death in young adults due to arrhythmias. Septal myectomy is a surgical treatment for HCM with moderate to severe outflow tract obstruction, and is indicated for patients with severe symptoms refractory to medical therapy. The surgical approach involves obtaining access to the interventricular septum via transaortic, transapical or transmitral approaches, and excising a portion of the hypertrophied myocardium to relieve the outflow tract obstruction. Large, contemporary series from centres experienced in septal myectomy patients have demonstrated a low early mortality of <2%, excellent long-term survival that matches the general population, and durable relief of symptoms.

ASSA14-14-05 Initial experience of occluding special type patent ductus arterioses using the Amplatzer vascular plug I

<h3>Background</h3> Occluders licensed for clinical use are not fit for some special Krichenko E patent ductus arterioses (PDA). The Amplatzer vascular plug I (Plug I) has not been licensed for use for closure of PDA. We report our initial experience to occluding special type PDA with the Plug I. <h3>Methods</h3> Patients referred with small and long Krichenko E PDA 1–3 mm in diameter underwent occlusion using this Plug I, this is a single lobe device of single layer Nitinol mesh for short vessel landing zones. All cases underwent pre-, intra- and post-procedural echocardiography at the completion of the procedure the next day and at a 30-day follow-up visit. Device sizing for device waist diameter and length was based on aortography. <h3>Results</h3> 26 patients with a median age of 5 years (range 6 months – 32 years) and a median weight of 19 kg (range 7–67 kg) underwent successful PDA closure. The median ductus diameter was 2.2 mm (range 1–3 mm). Both transpulmonary (22/26) and transaortic approaches (4/26) were used. No persistent patency was observed after 24 h and one month. <h3>Conclusions</h3> The Plug I Makes it easy to close some Krichenko E PDAs. Smaller delivery catherter profile and symmetric cylindrical device shape allow for use for small and long Krichenko E PDA 1–3 mm in diameter and small patients through transaortic approaches. Broader experience is required to further delineate device and patient selection as well as to document its long-term efficacy and safety.

Cardiac tamponade after transcatheter aortic valve replacement using a transaortic approach.

Transcatheter aortic valve replacement (TAVR) is considered an option for patients with severe aortic stenosis who are not surgical candidates. We describe the case of a patient who presented with cardiac tamponade shortly after uneventful TAVR by a direct aortic approach. The patient was brought to the operating room for exploration and repair. Although TAVR is less invasive than traditional open aortic valve replacement, TAVR nonetheless poses serious risk. This case highlights a potential complication of the less commonly used transaortic approach for TAVR and the importance of taking a multidisciplinary approach when identifying and managing all TAVR-associated complications.

Alternative access for balloon-expandable transcatheter aortic valve replacement: Comparison of the transaortic approach using right anterior thoracotomy to partial J-sternotomy

For transcatheter aortic valve replacement (TAVR), transaortic (TAo) and transapical (TA) approaches are major alternatives in cases unsuitable for the transfemoral approach. Partial J-sternotomy is a widely used access for TAo. However, redo sternotomy or right-sided aorta may preclude this access, and right anterior thoracotomy is potentially beneficial in these cases. This study sought to evaluate the TAo approach using thoracotomy (T-TAo) and compare it to the TAo approach using a sternotomy (S-TAo) and a TA approach. In a large single-center series, consecutive TAVR patients were studied. Procedural/clinical outcomes of the T-TAo, S-TAo, and TA groups were compared up to a 30 days follow-up period. Of 872 TAVR patients, 22 (2.5%) were T-TAo, 29 (3.3%) were S-TAo, and 86 (9.9%) were TA approaches. The TA group showed the shortest intensive care unit stay, with a median 2.0 (interquartile range 1.0-3.0) days: for T-TAo it was 3.0 (2.0-5.3) and for S-TAo, 3.0 (3.5-5.0) (P < .001). Although it was not statistically significant, the T-TAo group showed numerically less mortality (1 [4.5%], 5 [17.9%], and 8 [9.4%] in the T-TAo, S-TAo, and TA groups, respectively; P = .30), with no difference in other endpoints, including stroke/transient ischemic attack, rehospitalization, and paravalvular leak. Additionally, computed tomographic assessment revealed that T-TAo facilitated a more coaxial approach than S-TAo: 20.4° ± 8.2° versus 30.6° ± 8.2° (P < .001). T-TAo is a feasible approach that can provide greater coaxiality. This option allows tailored and optimal access to the individual patient and facilitates a treatment strategy in nontransfemoral TAVR patients.

Controversies and complications in the perioperative management of transcatheter aortic valve replacement.

Transcatheter aortic valve replacement (TAVR) is performed with increasing frequency in the United States since Food and Drug Administration approval in 2011. The procedure involves the replacement of a severely stenosed native or bioprosthetic aortic valve with a specially constructed valvular prosthesis that is mounted onto a stent, without the use of cardiopulmonary bypass and the complications of a major open surgical procedure. TAVR has been performed mostly in elderly patients with multiple comorbidities or who have undergone previous cardiac surgery. The most commonly used access routes are the femoral artery (transfemoral) or the cardiac apex (transapical), but the transaortic and transubclavian approaches are also used with varying frequency. Conscious sedation may be used in patients undergoing transfemoral TAVR, but the use of general anesthesia has not been shown to carry greater risk and permits the use of transesophageal echocardiography to assist in valve positioning and diagnose complications. Cardiovascular instability during TAVR is relatively common, necessitating invasive monitoring and frequent use of vasoactive medications. Complications of the procedure are still relatively common and the most frequent is vascular injury to the access sites or the aorta. Cardiovascular collapse may be the result of major hemorrhage pericardial effusion with tamponade or coronary occlusion due to incorrect valve placement. Persistent hypotension, myocardial stunning, or injury requiring open surgical intervention may necessitate the use of cardiopulmonary bypass, the facilities for which should always be immediately available. Ongoing and planned trials comparing conventional surgery with TAVR in lower risk and younger patients should determine the place of TAVR in the medium- to long-term future.

Transcatheter aortic valve implantation using a direct aortic approach: a single-centre Heart Team experience.

The transaortic (TAo) approach has been introduced as an alternative to transapical and transaxillary aortic valve implantation for patients with symptomatic severe aortic stenosis in whom a transfemoral approach is not feasible. However, only very limited data from a minimal number of specialized centres are available on this approach. Therefore, the aim of this study was to evaluate the early postoperative 30-day outcomes of the direct aortic approach performed by a single-centre multidisciplinary Heart Team. Between May 2011 and July 2013, 159 patients underwent transcatheter aortic valve implantation (TAVI) at our institution; of which, 44 were believed to benefit most from the TAo as assessed by a multidisciplinary Heart Team. All patients underwent an upper 'J' median hemi-sternotomy through a 6-cm incision. The evaluation of early operative results was made according to the Valve Academic Research Consortium (VARC) consensus criteria. These include device success endpoints and combined safety endpoints at 30 days. The mean age of the patients was 78 years, the mean logistic EuroSCORE was 25.9 ± 14.4% and the mean Society of the Thoracic Surgeons score 5.8 ± 4.5%. Seventeen patients (39%) underwent redo operations; 4 (9%) received a transcatheter valve in a degenerated bioprosthesis. The procedure was performed using the Medtronic CoreValve Revalving system in 36 patients, with the Edwards SAPIEN XT in 7 cases and the St Jude Medical Portico valve in 1. Device success was achieved in 90.8% of the cases. Complications included; major stroke (n = 1), re-exploration for cardiac tamponade (n = 3), transient renal failure requiring temporary haemodialysis (n = 1) and permanent pacemaker implantation (n = 5). There were no myocardial infarctions. The total 30-day mortality rate was 6.8% (3 patients). Postoperative intensive care unit stay was 2.6 ± 3.6 days, and the mean hospitalization was 12 ± 9.6 days. The TAo TAVI approach is feasible and offers a safe alternative for patients in whom a transfemoral approach is not feasible or desirable.

Transthoracic Access for Transcatheter Aortic Valve Replacement: Technique Using the Edwards Sapien Retroflex Delivery System

We describe our experience using the Edwards Sapien transfemoral Retroflex 3 catheter delivery system for transcatheter aortic valve replacement through the transapical and transaortic approaches. Transthoracic transcatheter valve replacement by the transapical and transaortic approaches can be safely and effectively performed with the Retroflex 3 delivery catheter, which affords several advantages over other available delivery devices.

Ventricular arrhythmias arising from the left ventricular outflow tract below the aortic sinus cusps: mapping and catheter ablation via transseptal approach and electrocardiographic characteristics.

Ventricular arrhythmias (VAs) originating from the anterosuperior left ventricular outflow tract (LVOT) represent a challenging location for catheter ablation. This study investigates mapping and ablation of VA from anterosuperior LVOT via a transseptal approach. This study included 27 patients with symptomatic VA, of which 13 patients had previous failed ablations. LVOT endocardial 3-dimensional mapping via retrograde transaortic and antegrade transseptal approaches was performed. Previous ECG markers for procedure failure were analyzed. In all patients, earliest activation with low-amplitude potentials was identified at the anterosuperior LVOT 5.1±2.8 mm below the aortic cusp and preceded the QRS onset by 39.5±7.7 ms only via an antegrade transseptal approach using a reversed S curve. In all patients, pace mapping failed to demonstrate perfect QRS morphology match. The anatomic location was below the left coronary cusp in 16, below the left coronary cusp/right coronary cusp junction in 8, and below the right coronary cusp in 3 patients. Radiofrequency energy resulted in rapid disappearance of VAs in all patients. ECG analysis showed aVL/aVR Q-wave amplitude ratio >1.4 in 7, lead III/II R-wave amplitude ratio >1.1 in 10, and peak deflection index >0.6 in 11 patients. There were no complications or clinical VA recurrence during a mean follow-up of 8.4±2.5 months. The anterosuperior LVOT can be reached via a transseptal approach with a reversed S curve of the ablation catheter. The rapid effect from radiofrequency energy indicates that the VA is most likely located under the endocardium. Also, previous ECG markers for procedure failure need further investigation.