Transcarotid as an Alternative Access Route for Trancatheter Aortic Valve Implantation
Damian Hudziak, MD PhD, Rados?aw Goco?, MD PhD, Wojciech Wojakowski, Prof, Andrzej Ocha?a, Prof, Rados?aw Parma, MD PhD, Joanna Ciosek, MD PhD, Micha? Lelek, MD PhD, Leszek Machej, MD PhD, Marek A. Deja, Prof
Medical University of Silesia, Katowice, Poland
BACKGROUND: Transfemoral (TF) is the most commonly used access for trancathehter aortic valve implantation (TAVI) due to the best safety profile and favorable long-term outcomes. Alternative access must be used in 15-20% TAVI candidates due to significant peripheral artery disease (PAD) and significant descending aortic disease. TAVI procedure through the common carotid artery (CCA) seems to be a promising alternative approach, for high-vascular-risk patients.METHODS: The approach was selected by a multidisciplinary (cardiologists and cardiac surgeons) heart team after analyzing preoperative coronary angiography, transthoracic echocardiography (TTE) and Multi-Slices Computed Tomography MSCT of the peripheral arteries. Patients with the following conditions were qualified to the transcarotid access: severe PAD (stenotic, heavily calcified), tortuous or small diameter < 6 mm iliofemoral arteries, descending and abdominal aortic disease (an aneurysm, thrombus, stentgraft). RESULTS:Thirty-three TC TAVI procedures were performed in our hospital from September 2017 to November 2019. There were one in-hospital death no related to access (rupture aortic ring) and one cerebrovascular complication (TIA). 30-day mortlity was 6,1%. The procedural success rate defined as the implantation of the valve with no coronary obstruction and less than moderate paravalvular leak (PVL) was 94%. Parameters of regional cerebral oximetry were symmetrical on the implantation and opposite side in all cases and only during rapid ventricular pacing transiently decreased below the value of 50%. (significantly lower on the implantation side). Postoperative myocardial infarctions was observed in one patient (3%). Statistically significant reduction of the echocardiographic parameters (PGmax and PGmean, Vmax) were observed. Paravalvular leak > 2 grade occurred in 2 patients (6,1 %). Additionally, the heart failure symptoms diminished after the procedure from a median class III to class II. Echocardiographic parameters are comparable to fourth postoperative day.CONCLUSIONS:Our results show that TC approach is feasible and safe. With proper preprocedural imaging and planning as well as patients selection TC access became our first-choice alternative approach for TAVI.