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Reducing Complications in Transapical Aortic Valve Replacement by Using Selective Axillary Cardiopulmonary Bypass
Alessandro Montecalvo, MD, Alan Zajarias, MD, John M. Lasala, MD, PhD, Brian R. Lindman, MD, Sunil M. Prasad, MD, Jennifer M. Bell, BSN, Ralph J. Damiano, Jr., MD, Hersh S. Maniar, MD.
Washington University in St. Louis, St. Louis, MO, USA.
OBJECTIVE: Transcatheter aortic valve replacement (TAVR) is an effective therapy for patients with aortic stenosis that are either high-risk or inoperable. At most centers, the transfemoral route of implantation is preferred, with the transapical (TA) approach limited to patients without suitable femoral access. A principal disadvantage of the TA approach is the difficulty in maintaining surgical control of the left ventricular (LV) apex. This report evaluated the use of selective cardiopulmonary bypass (CPB) during TAVR for the TA approach.
METHODS: Between January 2008 and October 2011, 104 consecutive TAVR procedures were performed, 50% via TAVR-TA (n=52). After 23 consecutive successful TAVR-TA cases, LV complications arose in 3 consecutive patients, all without previous cardiotomy and a mean age of 89±1.5 years. For future elderly, “virgin chest” patients, we implemented a strategy of elective CPB via axillary artery and femoral vein (CPB-AX) to completely decompress the ventricle during sheath removal. TAVR-TA outcomes were compared for patients with CPB-AX (n=6) versus those without (n=43).
RESULTS: Patients selected for CPB-AX were older (89±3 vs 83±6 years, p=0.025) but with a similar overall STS risk score (10.1±3.8 vs 12.8±5.1, p=0.14). Despite longer operative time (minutes) for the CPB-AX group (222±35 vs 133±40, p=0.00001), patients were similarly extubated in the operating room (100% vs 74.4%, p=0.31). Average CPB time for the CPB-AX group was 14.2±9.1 minutes. There was a trend towards a shorter ICU stay (hours) for the CPB-AX group (38±32 vs 82±121, p=0.06), but the overall length of hospital stay (days) was similar for both groups (8±2.5 vs 8.2±6.6, p=0.9). There were no cases of stroke or TIA in the CPB-AX group. After the implementation of elective CPB-AX in select patients, there have been no further LV apical complications. Overall 30-day mortality was similar for the CPB-AX and non CPB-AX groups (16% vs 7%, respectively, p=0.4).
CONCLUSIONS: Although elective use of CPB-AX does increase operative time, it does not appear to increase morbidity with respect to mechanical ventilation, stroke, or hospital stay. Most importantly, this short period of peripheral CPB appears to improve safety of TAVR-TA by reducing LV apical complications in selected patients.
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