Technical considerations to avoid pitfalls during transapical aortic valve implantation

Objective

Transapical aortic valve implantation is a recent therapeutic advance for aortic valvular disease. We sought to identify complications—and the relevant technical and management considerations—from our learning curve with this procedure.

Methods

We retrospectively reviewed perioperative complications during the first 60 transapical aortic valve implantations at a single institution, performed under compassionate release for patients who were candidates neither for conventional aortic valve replacement nor for transfemoral aortic valve implantation. Access was through a small left anterolateral thoracotomy. Particular attention was paid to securing the apical access site. Rapid ventricular pacing to reduce cardiac forward flow was used during balloon valvuloplasty and valve deployment. Careful positioning was guided by echocardiography and fluoroscopy.

Results

This was a select, high-risk (mean Society of Thoracic Surgeons score, 12.3% ± 7.8% mortality) cohort. Mean age was 81.1 ± 7.8 years. Technical success was achieved in 59 (98.3%) cases. One valve was malpositioned too far toward the ventricle, necessitating that a second device be implanted within it. In-hospital, 30-day mortality was 18.3% (11 deaths) overall, decreasing from 33.3% in the first 15 patients to 13.3% in the subsequent 45 patients. The only intraoperative death probably resulted from left main ostial obstruction by extensively calcified aortic cusps. Significant left ventricular apical bleeding occurred in 3 (5.0%) patients. Other complications included stroke in 2 (3.3%) patients and permanent atrioventricular block in 3 (5.0%). There were 4 (6.6%) cases of late pseudoaneurysm of the left ventricular apical access site.

Conclusions

Important lessons have been learned from our early experience with transapical aortic valve implantation, and these may guide others as this technology is adopted more broadly.

CTSNet Classification: 28, 35.2

Abbreviations and Acronyms: AVR, aortic valve replacement, LV, left ventricle (ventricular), TAVI, transapical aortic valve implantation, TEE, transesophageal echocardiography