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OBJECTIVE: We report our up-to date series for an alternative approach through the ascending aorta to implant Edwards SAPIEN THV valve in aortic position. We discuss in detail the technical aspects, the surgical advantages and future application of this novel approach. That might revolutionise surgical perspective on TAVI.
METHODS: All patients were accepted through the multidisciplinary team. Conventional approach i.e. Transfemoral (TF) or Transapical (TA) was either not possible or desirable and ascending aorta was deemed suitable for cannulation. Procedure was performed under GA guided by fluoroscopy and 3-D transesophageal echo (TEE). We will describe the procedure in detail.
RESULTS: 40/237(17%) patients underwent the procedure. Median age was 86(67-94years) with mean Logistic EuroSCORE of 27.2%. All patients had critical stenosis with mean AVA 0.67cm2, PG 72.5mmHg and LVEF49%. Successful device implantation was achieved in all cases without any postoperative complications directly related to the approach. The incidence of chest sepsis, renal failure and stroke was 6.06%, 12.1% and no strokes compared to 12.2%, 12.8% and 4.85% compared to the TA and TF groups. This is despite higher incidence of co-morbidities (COPD, 17/40(42.5%) vs. 23/204(11.2%)p0.01; severe extra-cardiac arteriopathy, 10/40(25%) vs. 25/204(12.2%)p0.02 and >50% internal carotid artery occlusion 12/33(34.3%) vs. 37/204(18.1%)p0.001 in this cohort compared to the TA and TF routes. There were no procedure deaths. Kaplan-Meier analysis showed survival at 81.8%, 70%, 60% and 55% at 1month, 6months, 1year and 2years which followed the survival curve for TF patients with slightly higher overall survival in the TA group.
CONCLUSIONS: We have successfully used the trans-aortic route in patients deemed unsuitable for conventional approaches. TA approach is technically always feasible but not necessarily desirable in patients with severe chest deformity, poor lung function, previous pulmonary complications and extremely poor ventricular function. Thoracotomy is associated with pain and risk of pleural effusion which can complicate recovery. The advantages of partial sternotomy are the avoidance of these complications and preservation of respiratory dynamics, as the pleura remain intact. LV function is preserved by avoidance of ventricular purse-stings. Future modification of delivery devises might make this procedure more amiable as a default surgical route for TAVI.