Transapical Approach Research Articles

Transapical Approach to Myectomy for Midventricular Obstruction in Hypertrophic Cardiomyopathy

Midventricular obstruction in hypertrophic cardiomyopathy (HCM) is less common than subaortic obstruction, and there are few data on outcomes after surgical treatment. We reviewed 56 consecutive patients (28 men) with HCM and midventricular obstruction who underwent myectomy between February 1997 and June 2012. Five patients had prior myectomy for subaortic obstruction. Mean age was 42 ± 17 years. Preoperatively, 51% of patients had dyspnea, and the remaining had palpitations (25%), angina (5%), or syncope (9%). Midventricular obstruction was relieved by means of a transaortic myectomy in 5 patients, a transapical approach in 32 patients, and combined transaortic and transapical incisions in 19 patients. In 13 patients, an apical aneurysm or pouch was repaired at the time of midventricular myectomy. There were no early deaths. Intraoperative intraventricular gradients were reduced from 64 ± 32 mm Hg before myectomy to 6 ± 12 mm Hg postoperatively (p ≤ 0.0001). Early complications included atrial arrhythmias in 5 patients and reoperation for bleeding in 4 patients. Fifty patients had follow-up beyond 30 days (median, 1.6 years; range, 33 days to 13 years). Survival at 1 and 5 years was 100% and 95%, and average New York Heart Association class improved from 2.9 ± 0.7 preoperatively to 1.3 ± 0.6 postoperatively (p = 0.0001). There were no aneurysms related to the apical incision; 2 patients had late reoperation, 1 for resection of right atrial mass to prevent embolus. A transapical approach allows excellent exposure for midventricular myectomy and relief of intraventricular gradients and related symptoms. There were no complications unique to the apical incision, and 5-year survival was similar to expected survival (95% versus 97%).

Transapical extirpation of a left ventricular thrombus in takotsubo cardiomyopathy

A 58-year-old Japanese female was referred to our hospital. Although the electrocardiogram showed ST elevation, coronary angiography showed intact coronary artery. We diagnosed Takotsubo cardiomyopathy and a left ventricular thrombus. Anticoagulation was administered; however, the left ventricular thrombus had become mobile and protrusive. We extirpated the left ventricular thrombus via trans-apical approach. Left ventricular thrombus is rare in Takotsubo cardiomyopathy, but these patients are at a higher risk of thromboembolism, especially if the thrombi are mobile and protruding.

Severe Aortic Regurgitation, Aortic Valve Preserving Procedures: A Viable Alternative to Prosthetic AVR

Severe Aortic Regurgitation, Aortic Valve Preserving Procedures: A Viable Alternative to Prosthetic AVR

A Review of Most Relevant Complications of Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) has emerged for treating aortic stenosis in patients who are poor candidates for surgical aortic valve replacement. Currently, the balloon-expandable Edwards Sapien valve—which is usually implanted via a transfemoral or transapical approach—and the self-expanding CoreValve ReValving system—which is designed for retrograde application—are the most widely implanted valves worldwide. Although a promising approach for high-risk patients, the indication may be expanded to intermediate- and eventually low-risk patients in the future; however, doing so will require a better understanding of potential complications, risk factors for these complications, and strategies to individualize each patient to a different access route and a specific valve. This paper reviews the most relevant complications that may occur in patients who undergo catheter-based aortic valve implantation.

The STS score is the strongest predictor of long-term survival following transcatheter aortic valve implantation, whereas access route (transapical versus transfemoral) has no predictive value beyond the periprocedural phase

Transcatheter aortic valve implantation (TAVI) was developed as a promising new therapy for inoperable and surgical high-risk patients as an alternative to traditional aortic valve replacement. After a successful procedure, prognosis may mainly be determined by comorbidities. However, no appropriate risk score to predict long-term outcome following TAVI is currently available. The aim of this study was to identify predictors of adverse short- and long-term outcomes. This is a two-centre registry study including a total of 426 TAVI procedures (274 transfemoral [TF] and 152 transapical [TA]) performed at the University Hospital and CardioVascular Center of Frankfurt (Germany) between 2005 and 2011. Observed 30-day mortality was 4.8% among TF and 12.6% among TA patients (hazard ratio [HR] TF vs TA was 0.38; 95% confidence interval [CI] 0.19-0.77). Patients with a higher Society of Thoracic Surgeons (STS) score experienced a 6% elevation in the 30-day mortality per point (HR 1.06; 95% CI 1.03-1.10), whereas the predictive value of the logistic EuroSCORE (HR 1.03; 95% CI 1.01-1.05) and EuroSCORE 2 (HR 1.04; 95% CI 1.01-1.07) was slightly lower. Most interestingly, older age (>80 years) and the access type were predictors of 30-day mortality. However, the only independent predictor of long-term mortality in a 30-day landmark analysis was the STS score (HR 1.05; 95% CI 1.02-1.09). The STS score outperforms the logistic EuroSCORE in predicting adverse outcomes following TAVI. The transapical approach is associated with higher perioperative mortality, but does not exert any influence on long-term prognosis beyond the periprocedural phase.

Percutaneous interventricular septal access in a patient with aortic and mitral mechanical valves: A novel technique for catheter ablation of ventricular tachycardia

Catheter ablation of ventricular tachycardia (VT) is typically performed using either the atrial transseptal approach or a retrograde aortic approach in order to gain access to the left ventricle (LV). However, neither approach is feasible in the setting of mechanical aortic and mitral valve replacements, given the risk of catheter entrapment and death.1, 2 Therefore, approaches that avoid traversing these valves, such as a percutaneous trans-apical approach, have been developed.3-6 However, the trans-apical approach is associated with a significant rate of access related complications, particularly bleeding at the puncture site, and necessitates the placement of closure devices in the LV.7, 8 We describe a novel percutaneous inter-ventricular transseptal puncture technique and placement of a sheath across the inter-ventricular septum for catheter ablation of VT. This method allowed for stable LV access and spontaneous closure of the septal access site.

Transapical Implantation of a Melody Valve in a Degenerated Low-Diameter Prosthetic Aortic Valve

78-year-old woman had undergone a biological aortic valve replacement (Mitroflow Pericardial, Sorin Inc, Burnaby, BC, Canada) and coronary artery bypass graft surgery 8 years previously. Acute exacerbation of her symptoms resulting from prosthetic aortic valve stenosis caused respiratory failure, necessitating resuscitation and mechanical ventilation. A transthoracic Doppler echocardiogram demonstrated peak and mean prosthetic aortic valve gradients of 70 and 51 mm Hg, respectively, and a calculated valve area of 0.5cm 2 (Figure 1). Coronary angiography demonstrated triple-vessel disease and 3 patent grafts to all coronary territories. Although the need for a tracheostomy and the seeming adherence of patent grafts to the sternal plate precluded conventional surgical intervention, the prosthetic valve size of 19 mm deemed the patient unsuitable for a conventional transcatheter aortic valve implantation. A Melody valve (Medtronic Inc, Santa Ana, CA), because of its suitability for annular diameters of 16 to 22 mm, was a possible solution. A surgical transapical approach was chosen because of the limitations of the Melody transvenous delivery system, poor vascular access, and the need for absolute control during the procedure. A pediatric cardiologist (E.B.) familiar with the Melody system was integrated into the team. The valve delivery system, Ensemble, is a balloon-in-balloon over-the-wire catheter onto which the valve is hand crimped. The level of expansion of the valve is determined by the size of the outer balloon used for inflation (range, 18–22 mm). The balloon and Melody valve are covered by a movable sleeve that is retracted before positioning and deployment with 22F profile that could easily be advanced through a 24F Ascendra-2 transapical sheath (Ascendra Inc, Reston, VA) originally designed for Edwards-XT transcatheter aortic valve implantation with its radiopaque markers and a reliable hemostatic seal. The femoral vessels were accessed for transvenous pacing and an aortic root marker pigtail catheter. The working angle was determined to be perpendicular to the Mitroflow ring (Figures 2 and 3). To avoid unequal valve expansion and to verify the true inner diameter of Mitroflow, we predilated the stenotic valve with a Nucleus 18-mm balloon (NuMed Inc, Hopkington, NY; Figure 4). After the valvuloplasty, the Melody delivery system was introduced via the Ascendra-2 sheath and positioned in a 50:50 position through the valve

Two Specialty Societies to Run Their Own Clinical Trial of Heart Valve Replacement

THE AMERICAN COLLEGE OF CARdiology (ACC) and the Society of Thoracic Surgeons (STS) will conduct a clinical trial exploring the safety and efficacy of expanded uses of transcatheter aortic valve replacement (TAVR) in certain types of patients with severe aortic stenosis. The trial is believed to be the first for any medical specialty societies. Aortic stenosis is a long-developing condition that, once symptoms emerge, is highly lethal. Roughly half of all untreated patients die in the first 2 years after symptoms appear. Surgical replacement of the valve reduces symptoms and improves survival, but at least 30% of patients with severe symptoms do not undergo surgery because of advanced age (most patients who develop symptoms are older than 80 years), left ventricular dysfunction, or comorbid conditions. With almost a third of all patients ineligible for surgery, researchers began looking for other means of valve replacement. In 2011, the US Food and Drug Administration (FDA) approved the SAPIEN transcatheter heart valve (Edwards Lifesciences) to treat aortic stenosis. The FDA approved TAVR only through the transfemoral approach for patients deemed inoperable or the transfemoral or transapical approaches for highrisk patients eligible for surgery. Edwards Lifesciences, along with physicians and hospitals, also agreed to participate in the Transcatheter Valve Therapy (TVT) Registry developed and run by the ACC and the STS. Participating in the TVT Registry allows physicians and hospitals to comply with Medicare’s national coverage determination for TAVR that ensures federal reimbursement for FDAapproved use of TAVR. But the national coverage decision was conditional: physicians would be reimbursed for performing TAVR only for the FDA-approved indications, meaning Medicare would not pay for procedures performed in an off-label manner—unless such patients were

First-in-man evaluation of the transapical APICA ASC access and closure device: the initial 10 patients

The aim of this study was to evaluate the initial and short-term results of a new apical access and closure device to facilitate and standardize the transapical (TA) approach to transcatheter aortic valve implantation (TAVI). The apical access, stabilization and closure (ASC™) device consists of three components: an introducer system, a left ventricular low-profile titanium coil and a closure cap. The ASC™ introducer system is anchored and rotated into the myocardium almost like a corkscrew, using the titanium coil. Following the TA-AVI procedure, the closure cap is introduced and delivered through the system into the titanium coil for final sealing. A total of 11 high-risk elderly patients (EuroSCORE I: 27.8 ± 16.7; EuroSCORE II: 6.6 ± 5.0 and The Society of Thoracic Surgeons (STS) score: 5.9 ± 2.7%) were evaluated for TA-AVI by our interdisciplinary Heart Team and subsequently included in the trial after informed consent was obtained. One patient was excluded due to the presence of deep epicardial fat tissue. In all other cases, the titanium coil provided sufficient sealing throughout the procedure without the presence of perisheath bleeding. After delivery of the closure cap, no relevant bleeding was observed in any patient. Pericardial drainages were removed early in all patients. One patient suffered from non-device-related pericardial effusion requiring surgical decompression on postoperative day 6. Two patients suffered from delayed minor strokes, most likely due to arrhythmia. All patients received aspirin, clopidogrel and low molecular heparin after the procedure. Discharge echocardiography revealed no changes in left ventricular function when compared with baseline and no new onset wall motion abnormalities. All 10 patients were alive at 30 days. TA access and closure are both feasible and safe using the APICA ASC™ device. The system facilitates and standardizes TA access and closure by providing a sufficient and secure sealing during and after the TA-AVI procedure.

Transcatheter aortic valve implantation: Is anatomy still the limiting factor?

IntroductionDespite rapid advances in transcatheter aortic valve prostheses, anatomical constraints remain that can limit access to this treatment for patients with severe aortic stenosis. The objective of this study was to determine the proportion of patients anatomically suitable for this technique using the different devices and approaches available. MethodsWe retrospectively analyzed 145 consecutive patients referred to our center for transcatheter aortic valve implantation. Aortic annulus diameter was measured by transesophageal echocardiography and minimum iliofemoral diameter was determined by multidetector computed tomography. We determined the proportion of patients anatomically suitable for current devices (26-mm, 29-mm and 31-mm Medtronic CoreValve for transfemoral, transaxillary or transaortic approaches, and 23-mm, 26-mm and 29-mm Edwards Sapien XT for transfemoral or transapical approaches). ResultsThe Medtronic CoreValve was suitable for 89% of patients via transfemoral access and 93.8% via transaxillary or transaortic approaches, while the Edwards Sapien XT was suitable for 82.1% of patients via transfemoral and 97.2% via transapical approaches. Only 1.4% of patients were anatomically unsuitable for all devices and approaches. ConclusionsIn this population, most patients were anatomically suitable for transcatheter aortic valve implantation if assessed on the basis of multiple devices and multiple access approaches.

Transcatheter aortic valve implantation: Single center experience with mid-term follow-up

Transcatheter aortic-valve implantation (TAVI) is an emerging intervention for the treatment of high-risk patients with severe aortic stenosis and coexisting illnesses. Between August 2009 and May 2012, we have conducted a retrospective study underwent a balloon expandable transcatheter xenograft (Edwards SAPIEN®) and evaluated the intermediate-term all cause mortality. Average STS and EuroSCORE II predicted risk for mortality was 18.4 ± 8.9% and 7.6 ± 5.5%, respectively. The end points included feasibility, safety, efficacy, and durability. A total of 27 consecutive patients underwent TAVI. Nine (33.3%) patients among them had it through the trans-apical approach. The mean age was 76 ± 8 years; 41% of the patients were females. There was 100% successful implantation. Hospital and one-year mortality were 2 (7.4%) and 4 (14.8%), respectively. At 1 year, the incidence of stroke was 1 (3.7%), infection 6 (22%), AV block 2 (7.4%), severe bleeding 2 (7.4%), vascular complication (14.8%), and the incidence of periprosthetic aortic regurgitation (<2) was 5 (18.5%). No patient been converted to open surgery. There was a significant improvement of patient left ventricular function post TAVI ( p = 0.001), and of aortic valve area (AVA) with mean 0.4 ± 01cm2 ranging from 0.2 to 0.9 cm2 pre-and 1 ± 0.3 cm 2 ranging from 1 to1.9 cm 2 post-TAVI ( p = 0.0001). The aortic pressure gradients have improved significantly from 45 ± 11 mm Hg pre-to 8.5± 5.5 mm Hg post-implantation ( p = 0.0001). For all patients the average length of follow-up by echocardiography was 346 days and was 100% completed. TAVI has provided good results in the initial 27 patients. However, The use of transcatheter aortic valve implantation should be restricted to the inoperable high-risk patients.

Survival outcome of 100 patients who underwent transcatheter aortic valve implantation (TAVI)

TAVI is a new alternative treatment for high risk patients with severe aortic stenosis (AS). The procedural success and survival have improved over time. We report the survival data of 100 patients who received TAVI at Prince Sultan Cardiac Center, Riyadh. Patient’s clinical, imaging and procedural data were collected in a data base, and they were followed at 6 month and yearly afterward. The survival data were derived using statistical software 100 patients underwent the procedure with mean age of 78.8 ± 8.8 years, 55% males, and 45 % females. 60% of patient received Edward’s valve, and 40% received Core valve. The procedural success was 95%. The 30 days mortality was 10% in patients who received Edward’s valve, and 5% in those received Core valve. The 1-year mortality was 21% in patients received Edward valve and 10% in those received Core valve. The 30 days mortality for patients who had trans-femoral Edward approach was 9%, and for those who had trans-apical approach was 11%. The 1-year mortality for trans-femoral Edward approach was 15%, and for the trans-apical approach was 30%. Elderly patients with severe AS and at high risk for surgery can undergo TAVI with high success rate, and acceptable mortality rate. The highest mortality rate at 1 year was in patients who underwent trans-apical TAVI.

Cost of transcatheter aortic valve implantation and factors associated with higher hospital stay cost in patients of the FRANCE (FRench Aortic National CoreValve and Edwards) registry

Currently, several anatomical approaches and intervention sites can be used to perform transcatheter aortic valve implantations (TAVIs), often with no clinical indications for choosing one or another. While these choices can have an impact on resource consumption, no costing study is available in the European context to provide information on resource use and assist decision-making. To provide comparative data on the cost of the TAVI procedure, depending on anatomical approach and intervention site used, from a hospital perspective, and to analyze factors associated with cost of hospital stay. Multicentre national registry data were collected in 16 centres between January and October 2009. For 287 patients, a descriptive costing study and a multivariable analysis of hospital stay cost were performed. The mean cost of the TAVI procedure was €22,876 and the mean initial hospital stay cost was €35,164. The procedure cost, excluding valve cost, did not differ between anatomical approaches and was highest in the hybrid room and lowest in the catheterization laboratory. Factors associated with higher hospital stay cost were transapical approach, Society of Thoracic Surgeons score>10%, warfarin use at inclusion, complications during procedure and pacemaker implantation following valve implantation. If clinical considerations do not interfere, hospital staff may find it economically favorable to opt for the catheterization laboratory and against the hybrid room. The mean hospital stay cost is higher than the tariff paid in 2011, a difference that has grown since the change in tariff in 2012, representing an economic disincentive for the uptake of TAVI in France.

Massive aortic regurgitation following paravalvular balloon valvuloplasty of an edwards sapien valve treated by emergent corevalve implantation: Never cross a transcatheter aortic valve without a pigtail

A 72-year-old patient, with a history of coronary artery bypass and aorto-bifemoral graft, was diagnosed with a symptomatic severe aortic valve stenosis in the presence of moderately decreased left ventricular function. The Heart team decision was to implant an Edwards SAPIEN XT 26 mm valve by transapical approach, therefore avoiding access through the aorto-bifemoral graft. At the end of the procedure, grades 2-3 aortic regurgitation was observed. Since each run of rapid pacing ended in ventricular fibrillation, it was decided to treat the aortic regurgitation conservatively with the option of post-dilation in a second procedure if hemodynamic deterioration was observed. Six days later balloon valvuloplasty was performed because of heart failure requiring endotracheal intubation. Despite transesophageal echocardiography guidance the balloon was inadvertently advanced through the paravalvular space. As a consequence, balloon valvuloplasty was complicated by massive aortic regurgitation and severe hemodynamic instability which was resolved after emergency transfemoral implantation of a CoreValve. Without any further complications, the patient was discharged eight days later.

Transcatheter valve-in-ring implantation after failure of surgical mitral repair

Redo surgery after failed mitral valve repair may be high risk, or contraindicated in patients with comorbidities. Because of this high risk, other interventional possibilities like transcatheter valve implantation might be of benefit. We report our experience with transcatheter mitral valve-in-ring implantation (TVIR) in high-risk patients after failure of surgical ring annuloplasty. From January 2010 to February 2012, following a multidisciplinary discussion, 17 high-risk patients underwent TVIR using Edwards SAPIEN XT prostheses, via either a transvenous transseptal (n = 8), or a transapical approach (n = 9). Patients were aged 70 ± 16 years, in New York Association classes III/IV. Their mean logistic EuroSCORE was 36 ± 17% and mean Society of Thoracic Surgeons risk score 13 ± 9%. The mean time interval between surgery and repair failure was 7 ± 3 years. Annuloplasty rings were semi-rigid in 14 cases, flexible in 2, and rigid in 1. Manufacturers ring diameters were 26 mm in 4 patients, 27 mm in 1, 28 mm in 9, 30 mm, 31 mm and 34 mm in 1. The predominant failure mode was regurgitation in 12 cases and stenosis in 5. SAPIEN XT diameters were 26 mm in 15 patients, 23 mm and 29 mm in 1. Procedural success rate was 88% (15/17). Emergency surgery was needed in 1 patient due to acute dislodgement of the ring. The degree of mitral regurgitation was reduced to none or mild in all but 2 patients; final mean gradient was 7 ± 3 mmHg. Thirty-day survival was 82% (14/17 patients). At last follow-up (13 ± 5 months), survival rate was 71% (12/17). These preliminary results suggest that TVIR is feasible, with low operative risk, and may provide short-term clinical and haemodynamic improvement in selected high-risk patients with failure of mitral ring annuloplasty.

Implantação percutânea de válvula aórtica: a anatomia é (ainda) o fator limitante?

IntroductionDespite rapid advances in transcatheter aortic valve prostheses, anatomical constraints remain that can limit access to this treatment for patients with severe aortic stenosis. The objective of this study was to determine the proportion of patients anatomically suitable for this technique using the different devices and approaches available. MethodsWe retrospectively analyzed 145 consecutive patients referred to our center for transcatheter aortic valve implantation. Aortic annulus diameter was measured by transesophageal echocardiography and minimum iliofemoral diameter was determined by multidetector computed tomography. We determined the proportion of patients anatomically suitable for current devices (26-mm, 29-mm and 31-mm Medtronic CoreValve for transfemoral, transaxillary or transaortic approaches, and 23-mm, 26-mm and 29-mm Edwards Sapien XT for transfemoral or transapical approaches). ResultsThe Medtronic CoreValve was suitable for 89% of patients via transfemoral access and 93.8% via transaxillary or transaortic approaches, while the Edwards Sapien XT was suitable for 82.1% of patients via transfemoral and 97.2% via transapical approaches. Only 1.4% of patients were anatomically unsuitable for all devices and approaches. ConclusionsIn this population, most patients were anatomically suitable for transcatheter aortic valve implantation if assessed on the basis of multiple devices and multiple access approaches.

Three-Dimensional Transesophageal Echocardiography Assessment of a Successful Transcatheter Mitral Valve in Valve Implantation for Degenerated Bioprosthesis

Reoperation for degenerated mitral bioprosthesis is considered a high risk procedure. Transcatheter mitral valve in valve implantation has emerged as an off-label alternative for patients contra-indicated to surgery. We report a 46-year-old man, with a 29 mm mitral bioprosthesis since 2002, who was admitted for acute heart failure because of a severe intra-prosthetic regurgitation. His recent medical history revealed a fast growing cavum carcinoma. In view of generally poor prognosis, the heart team decided to perform a transcatheter mitral valve in valve implantation by transapical approach. Live three-dimensional TEE was used during the implantation for sizing, device positioning, and hemodynamic assessment.

Left Ventricular Embolization of an Aortic Balloon-Expandable Bioprosthesis: Balloon Capture and Reimpaction as an Alternative to Emergent Conversion to Open-Heart Surgery

An 83-year-old man with severe symptomatic aortic stenosis, deemed to be high risk for conventional surgery (Logistic EuroSCORE 26.63%, Society of Thoracic Surgeons Score 7.2%) was referred to our institution for a transcatheter aortic valve implantation. A transapical approach was chosen, because

TRANSSEPTAL ANTEGRADE TRANSCATHETER AORTIC VALVE REPLACEMENT FOR NO–ACCESS OPTION PATIENTS: A CONTEMPORARY EXPERIENCE

Transcatheter aortic valve replacement (TAVR) was first done via the transseptal (TS) approach, but this was largely abandoned in favor of retrograde transfemoral (TF), transaortic (TAo) or transapical (TA) approaches. TS TAVR may still be warranted in patients for whom no other approach is feasible

INCIDENCE OF STROKE IN PATIENTS UNDERGOING TRANSCATHETER AORTIC VALVE REPLACEMENT USING EDWARDS SAPIEN VALVE FOR CRITICAL AORTIC STENOSIS. META–ANALYSIS COMPARING TRANSFEMORAL VERSUS TRANSAPICAL APPROACH

Trancatheter aortic valve replacement (TAVR) is associated with a higher risk of stroke as compared to surgical aortic valve replacement. The data on the difference in the incidence of stroke between the transfemoral (TF) vs transapical (TA) approaches is limited to individual studies. We performed