Transapical transcatheter aortic valve implantation in patients with aortic diseases

Abstract

OBJECTIVES Patients scheduled for transcatheter aortic valve implantation (TAVI) treatment frequently present with concomitant aortic diseases, in which case they are usually considered to be at high interventional risk and, in particular, unable to undergo the transfemoral TAVI approach. Since the establishment of the ‘transfemoral first’ strategy for TAVI, there has been an evidence gap with regard to the outcomes of such patients. We aimed to evaluate the mid-term outcomes after transapical TAVI in patients with diverse aortic diseases. METHODS Fifty-five consecutive elderly patients (78.4 years; standard deviation: 8.6 years) at intermediate surgical risk with severe aortic stenosis and aortic diseases (porcelain aorta 36%, ascending aneurysm 15%, descending aneurysm 26%, type-B dissection 4%, aortic thrombus 7%, Leriche syndrome 4%, aortic kinking 11%, aortic ulcer 2%, previous aortic operation 20%, aortic elongation/tortuosity 4%) underwent transapical TAVI treatment between January 2011 and November 2019 at our institution. We used the second-and third-generation self- and balloon-expanding valves. The follow-up time was 92.6 patient-years. RESULTS The Society of Thoracic Surgery-Predicted Risk of Mortality score was 7% (standard deviation: 4%). The 30-day mortality and all-stroke rates were 6% and 4%, respectively. The median survival time was 24.9 months (95% confidence interval 17.6–32.3). The median time of freedom from a composite of death and cardio-cerebral adverse events was 24.3 months (95% confidence interval 11.9–36.8). The rate of moderate/severe paravalvular leakage was 2%. The pacemaker rate was 10%. No early or late aortic syndrome occurred. CONCLUSIONS Transapical TAVI is a safe method and shows very promising early and mid-term outcomes, without early/late aortic syndrome, in patients with aortic diseases for whom transfemoral TAVI as the first-line transcatheter method might be contraindicated or not feasible.

Transapical‐transcatheter aortic valve implantation in patients without transvascular options: Modified transapical approach

“…Furthermore, the TA-TAVI procedure has shown good results in a specific TAVI population. 15 Therefore, this procedure should be considered an option.…”

“…In the SOURCE 3 Registry (72% of the patients underwent TA‐TAVI), the 30‐day mortality and stroke rates were 4% and 2.8%, respectively, whereas major vascular injuries occurred in 3.2% of the patients. Furthermore, the TA‐TAVI procedure has shown good results in a specific TAVI population 15 . Therefore, this procedure should be considered an option.…”

Transapical Transcatheter Aortic Valve Replacement: A Real-World Early and Mid-Term Outcome of a Third-Level Centre

“…Blackstone E.H. et al [ 18 ] reported 7.8% of in-hospital mortality for TA-TAVR in the sub-analysis of the first PARTNER trial. Other observational studies from TAVR registries reported an incidence of 30-day mortality ranging from 4% to 8% with contradictory findings when compared with a TF approach [ 8 , 9 , 10 , 19 , 20 , 21 ]. Our excellent results support a recent study [ 12 ] that highlights the relevance of the operators’ experience in achieving and maintaining optimal clinical outcome after transcatheter procedures.…”

“…In the last few years, different percutaneous vascular accesses (i.e., trans-carotid, trans-subclavian, trans-axillary) have gained great popularity as possible routes for TAVR, even if data are still limited [ 3 , 4 , 5 ]. Even though its use is decreasing, TA-TAVR still represents one of the alternative approaches supported by the greatest worldwide experience [ 6 , 7 , 8 , 9 ]. Moreover, the recent literature suggests that improved outcomes may be derived from more controlled TAVR programs in high-volume centres [ 10 , 11 ], and that the operator’s experience is the key to achieve and maintain the most favourable clinical results—especially in higher-risk subjects [ 11 , 12 ].…”

Left Ventricular Apex: A “Minimally Invasive Motorway” for Safe Cardiovascular Procedures

“…Over time, however, many centres gained valuable experience in managing the left ventricular apex and thanks to improvements in materials, were able to report satisfactory results for the transapical approach in patients unsuitable for the transfemoral procedure [10]. Some large propensity-score matching series with the transfemoral approach in fact showed no statistical difference in survival between the two accesses.…”