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DA-TAVI ("Direct Aorta Ascending Approach in TAVI")
Gry Dahle, MD, Kjell Arne Rein, MD.
Rikshospitalet, OUS, Oslo, Norway.

Objective
Direct aorta ascending approach is a new access way for TAVI, to be used in patients with peripheral vascular disease and as an alternative to transapical approach.
Methode
Both the Edwards SAPIEN and CoreValve systems were used. Depending on the course of the ascending aorta, the relation to sternum,the brachiocephalic vein, eventually veingrafts, LIMA and RIMA grafts from previous heart surgery, either mini-right thoracotomy or mini L-sternotomy was selected. CT-scan with reconstruction was applied for this decision-making. A hybride operating room was used with echocardiographic and fluoroscopy guidance.
Results
So far we have done 16 procedures via aorta ascendens. Mean age 79 years, 11 males. The mean Logistic EuroScore1 of 37 reflects the comorbidities. Two thirds of the patients had coronary vessel disease and had undergone CABG, one third had abdominal aortic aneurysm. Mean EF was 43% and the patients were in NYHA class 3-4. The mean gradient was 45 mmHg and mean valve area was 0,7cm2. Mean valve size was 29mm.The use of Edwards SAPIEN vs CoreValve was 9 vs 7 and thoracotomy vs sternotomy was 6 vs 10. All procedures were done successfully, but one patient had a periprocedural valve-in-valve.
All but three patients were extubated in the operation room. The patients stayed in the ICU over night. Four patients were reoperated: 1) chest tube to drain fluid 2) vascular reconstruction following the angio 3) pacemaker lead perforation and acute operation in ICU 4) redo open surgery due to paravalvular leak. The over all survival was 81% (follow up 0-14 months).
Conclusion
Access design is an important issue in TAVI. When central approach is needed, TAVI-DA is safe. For patients with low ejection fraction, the TAVI-DA is preferred to the TAVI-TA. The cannulation technique of the aorta is well known for cardiothoracic surgeons and the method is feasible both for the Medtronic CoreValve and Edwards SAPIEN valve, either via the right mini thoracotomy or the mini sternotomy in order to obtain the best coaxial alignement. It seems easier to position the bigger valves more precisely via this central approach.


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