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OBJECTIVE: Standard transapical access (TA) for the implantation of transcatheter aortic valve prosthesis (TA-AVI) requires a mini-thoracotomy and the use of a metal rib-retractor to expose the left ventricular apex (Figure A). We recently changed to a “no rib-spreading” approach using a soft-tissue retractor only (Figure B). This new technique is compared to the conventional approach by means of 1:1 propensity score (PS) matching.
METHODS: In total, 320 patients have been included (2011-2013). 19.1% of procedures had been performed with no rib spreading approach (“no-spreading”, n=61). To adjust for baseline variables propensity score (PS) based pair matching has been used.
RESULTS: Using the “no rib-spreading” technique all commercially available TA devices have been implanted and the apex was successfully controlled by standard purse-strings in all cases. In two cases exposure was inadequate and in one bleeding required insertion of a metal retractor. Two patients of the no-spreading group required a re-thoracotomy due to bleeding (chest wall).
PS-matching resulted in adequate bias reduction. Median procedure times were comparable (no-spreading 49 minutes vs. conventional 48 minutes, p=0.64). Functional outcomes regarding valve performance and 30-day mortality was comparable. The re-thoracotomy rate was similar (no-spreading 3.8% vs. conventional 3.8%, p=1.0). Bleeding events showed no significant difference (VARC minor/major: no-spreading 4.0%/none vs. conventional none/5.0%, p=0.13/0.07).
CONCLUSIONS: A “no rib-spreading” access is feasible and save in the majority of TA-AVI patients. The technique might further minimize surgical trauma without jeopardizing safety and might lead to an even better acceptance of the TA approach in general.