Direct Aortic Transcatheter Aortic Valve Implantation : A Feasible And Effective Alternative For Patients With Poor Peripheral Vascular Access
Simon CY Chow1, Randolph HL Wong1, Gary SH Cheung2, Eugene B. Wu2, Jacky Yk Ho1, Peter Sy Yu1, Malcolm J. Underwood1.
1Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin , New Territories , HK, Hong Kong, 2Division of Cardiology, Department of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin , New Territories , HK, Hong Kong.
BACKGROUND Transcatheter aortic valve implantation (TAVI) is established as a safe and effective treatment for patients at high risk for surgical aortic valve replacement (SAVR). However, some patients may not be suitable for transfemoral or transsubclavian approach due to severe peripheral vascular disease. The Trans-apical approach is associated with risks of left ventricular complications. The aim of this case series is to evaluate the feasibility and short term clinical outcomes of the direct aortic approach. METHODS From May 2015 to November 2017, 8 patients with severe symptomatic aortic stenosis were enrolled for direct aortic TAVI after multidisciplinary HEART team discussion. They were considered to be of high to prohibitive surgical risks and ineligible for transfemoral approach due to small caliber peripheral vessels , iliofemoral or thoracoabominal aortic disease. RESULTSThe Evolut R Corevalve was successfully deployed in all 8 patients (mean age 79.6 +/- 3.8). The mean STS score was 8.4. We performed 7 right mini-parasternal incisions and 1 partial J sternotomy. There was no intraoperative mortality. There was 1 case of mortality 5 days post operation due to cardiac causes. None of the patients required permanent pacemaker implantation. 1 patient required reopening of the mini-parasternal incision for post-operative bleeding. Follow up echocardiogram 1-month after the operation showed improvement in mean gradient (63.2 mmHg to 8.3 mmHg) and aortic valve area (0.62 to 2.2 cm 2). None of the patients had more than mild paravalvular leakage. CONCLUSIONDirect aortic TAVI is an effective and feasible alternative approach for patients with severe aortic stenosis who are considered too high risk for SAVR and unsuitable for transfemoral TAVI. Long term data and comparison studies with other alternative approaches are needed to determine the role of direct aortic TAVI.
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