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Right Thoracotomy: The Access of Choice for Transaortic Transcatheter Aortic Valve Replacement.
Julius I. Ejiofor1, Morgan T. Harloff1, Marko T. Boskovski1, Siobhan McGurk1, Prem S. Shekar1, Lawrence H. Cohn1, Pinak Shah2, Tsuyoshi Kaneko1.
1Brigham and Women's Hospital, Division of Cardiac Surgery, Boston, MA, USA, 2Brigham and Women's Hospital, Division of Cardiology, Boston, MA, USA.

OBJECTIVE: Transcatheter aortic valve replacement (TAVR) is now a well established option in high risk patients with aortic stenosis. In cases unsuitable for the transfemoral approach, transaortic access offers an alternative approach. A right thoracotomy offers a better technical coaxial angle for transaortic TAVR implantation compared to a median sternotomy which may lead to less paravalvular leak. We report a series of transaortic TAVRs performed via right thoracotomy incisions with emphasis on technical success, morbidity and mortality.
METHODS: All TAVR patients in our cardiac surgery database from November 2011 to May 2015 were queried. Of 353 TAVRs, 42 cases of transaortic performed via right thoracotomy were identified for analysis. Median follow-up time was 1.5years (IQR 0.8, 2.2).
RESULTS: Mean age of the cohort was 80.7+/-8.4 years, and 26/42(61.9%) were women. At baseline, 31% were diabetics, 9.5% in renal failure, 7.1% had prior strokes, 11.9% prior myocardial infarctions. Mean ejection fraction was 55 +/-10.1 and 61.9% were in class III/IV NYHA heart failure. 47.6% had prior cardiac surgery and mean STS PROM score was 7.85.7. Balloon expandable valves were used in 40 patients (95%) and self expandable valves in the rest. Technical success rate was 97.6% (41/42). One patient required open conversion and cardiopulmonary bypass. Operative mortality was 7.2% (3/42). There were no reoperations for bleeding, no postoperative stroke and 7.1%(3/42) had new onset renal failure. No patient required permanent pacemaker postoperatively. Six patients (14.3%) had mild paravalvular leaks, none had more than moderate paravalvular leak. Median ICU and length of hospital stay was 45 (IQR 26, 68) hours and 7(IQR 5, 8) days respectively. One and two year survival were 73.7%(95% CI 60.3-87.1%) and 67.8%(95% CI 53.5-82.%) respectively.
CONCLUSIONS: Transaortic TAVR via a right thoracotomy allows accurate positioning and low rate of paravalvular leak. Right thoracotomy should be the access of choice for transaortic TAVR.

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