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OBJECTIVE:
Transcatheter aortic valve replacement is the newest procedure dedicated to the treatment of degenerated valves in old high-risk patients. This minimally invasive technique has a transfemoral and a transapical approach and requires a well defined preoperative plan to be performed in a safe environment with low risk of intraoperative complications.
METHODS:
From 2009 to 2011, we routinely perform transapical and transfemoral cases. All patients have a full screening and a preoperative rescue plan, with bailout procedures and alternative cannulation sites, is discussed in advance. The cardiopulmonary bypass (CPB) stand-by is always guaranteed. All data were collected and analyzed
RESULTS:
We performed a total amount of 150 transcatheter aortic valve procedures in 3 years (116 transapical and 24 transfemoral) using the balloon-expandable Sapien stent-valve platform. Mean age and logistic Euroscore were 83±8.3 years and 29±13.8% respectively. Valve-in valve procedures were 6 in degenerated stended bioprosthesis. The successful implantation rate was 99.3% with one case of distal stent-valve embolization. Following the preoperative plan, in two case of low LVEF we instituted a femoro-femoral CPB before the transapical procedures, with very good outcomes. Hospital mortality was 8.7%. Bailout procedures were the rescue Sapien-in-Sapien in 3 cases (2 for Sapien malfunctioning and 1 for severe paravalvular leak for a too low implanted Sapien), the emergency CPB use in two cases of major bleedings and a femoral vascular reconstruction during a transfemoral case. Major complications occurred were: severe apical bleeding (1), valve malfunctioning (3), left ventricular rupture (1), distal valve embolization (1), valve malpositioning (1), neurological events (4), severe paravalvular leaks (3).
CONCLUSIONS:
Transcatheter valve therapies are indicated in high-risk patients and preliminary results are satisfactory. The preoperative multidisciplinary discussion is more than ever required in order to identify helpful bailout procedures and alternative strategies in case of emergency.