Transaortic aortic valveimplantation with Sapien

Gian Luca Martinelli MDCV Surgery Dept.

S Anna Hospital – Catanzaro - Italy

VASCULAR ACCESS

Transfemoral

TransaorticTransapical

Transsubclavian

TFTF--AVI SURGICAL EXPOSUREAVI SURGICAL EXPOSURE

TATA -- AVIAVI

ALTERNATIVE APPROACHES

• Transsubclavian (generally left)

• Transaortic: two options

Minimal anterior thoracotomy Upper ministernotomy

CLINICAL PRESENTATION81 yo female

NYHA III

Good EF, severe aortic stenosis

Chronic pulmonary disease in medical treatment, cerebral and peripherical vascular disease

LogisticEuroScore 28%, EuroScore II 6%, STS score 7%

ECHOCARDIOGRAM

EF 45%, functional area 0,75 cm2, mean gradient 40 mmhg, peak velocity > 4 m/sec

ECHOCARDIOGRAM

MSCT SCAN

CHOICE OF MINISTERNOTOMY

Conventional approach, TF-AVI or TA-AVI, was not desirable AND the ascending aorta was deemed suitable for conventional cannulation

STEP BY STEP PROCEDUREA 5 cm J-shaped upper ministernotomy;

A 8-Fr sheath insertion through a double pledgets reinforced purse string sutures with the Seldinger technique;

Crossing aortic valve with a straight wire supported by a right Judkins catheter;

Insertion of a pre-shaping super stiff guide wire in left ventricle;

Finally the Ascendra 2 transapical delivery system is introduced through the aorta and kept in its upper part.

IDEAL STAIGHT LINE FOR OPTIMAL VALVE RELEASE

• A non-calcified area on the ascending aorta was identified which would allow direction of the sheath in a STRAIGHT LINE to deploy the device, leaving enough space between the Ascendra system and the device itself.

BALOON AORTIC VALVULOPLASTY

VALVE RELEASE

AORTIC ANGIOGRAM AND ECHOCARDIOGRAM CONTROL

THE DAY AFTER

• RX TORACE

LESSON LEARNED

• Procedural success: adequate technical placement, normal bioproshesis performance and recovery;

• Advantage: overcoming challenging aorto-ileo –femoral-vascular disease, avoid arch crossing and new left ventricular scar;

• The proximity between the puncture site and the native aortic valve allows easier manipulation and delivery of the device, with an IDEAL straight line.

CONCLUSIONS

• Upper ministernotomy represent an additional option for patients who are NOT candidates for TF-AVI and in whom an apical approach may represent a less desirable option (low EF, severe pulmonary disfunction);

• Access to arterial brachiocephalic trunk is also avaible through this incision;

• Controindication for transaortic TAo-AVI approach: porcelain aorta.