Original article
Adult cardiac
Transapical Aortic Valve Implantation Without Angiography: Proof of Concept

Presented at the Poster Session of the Forty-sixth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 25–27, 2010.
https://doi.org/10.1016/j.athoracsur.2010.02.047Get rights and content

Background

Cardiac computed tomographic scans, coronary angiograms, and aortographies are routinely performed in transcatheter heart valve therapies. Consequently, all patients are exposed to multiple contrast injections with a following risk of nephrotoxicity and postoperative renal failure. The transapical aortic valve implantation without angiography can prevent contrast-related complications.

Methods

Between November 2008 and November 2009, 30 consecutive high-risk patients (16 female, 53.3%) underwent transapical aortic valve implantation without angiography. The landmarks identification, the stent-valve positioning, and the postoperative control were routinely performed under transesophageal echocardiogram and fluoroscopic visualization without contrast injections.

Results

Mean age was 80.1 ± 8.7 years. Mean valve gradient, aortic orifice area, and ejection fraction were 60.3 ± 20.9 mm Hg, 0.7 ± 0.16 cm2, and 0.526 ± 0.128, respectively. Risk factors were pulmonary hypertension (60%), peripheral vascular disease (70%), chronic pulmonary disease (50%), previous cardiac surgery (13.3%), and chronic renal insufficiency (40%) (mean blood creatinine and urea levels: 96.8 ± 54 μg/dL and 8.45 ± 5.15 mmol/L). Average European System for Cardiac Operative Risk Evaluation was 32.2 ± 13.3%. Valve deployment in the ideal landing zone was 96.7% successful and valve embolization occurred once. Thirty-day mortality was 10% (3 patients). Causes of death were the following: intraoperative ventricular rupture (conversion to sternotomy), right ventricular failure, and bilateral pneumonia. Stroke occurred in one patient at postoperative day 9. Renal failure (postoperative mean blood creatinine and urea levels: 91.1 ± 66.8 μg/dL and 7.27 ± 3.45 mmol/L), myocardial infarction, and atrioventricular block were not detected.

Conclusions

Transapical aortic valve implantation without angiography requires a short learning curve and can be performed routinely by experienced teams. Our report confirms that this procedure is feasible and safe, and provides good results with low incidence of postoperative renal disorders.

Section snippets

Material and Methods

Between November 2008 and November 2009, 14 men and 16 females suffering from severe aortic valve stenosis underwent 30 consecutive TA-TAVI using 23 mm/26 mm Sapien stent-valves and Ascendra systems (Edwards Lifesciences, Irvine, CA).

All patients were extensively informed about the modified minimally invasive procedure and they all signed an informed consent following the guidelines of our internal ethical committee. All cases were performed under general anesthesia in the operating theater

Results

Preoperative patient characteristics are listed in Table 1. Thirty consecutive patients suffering from aortic stenosis underwent TA-TAVI in our center: the mean age and the calculated logistic EuroSCORE were 80.1 ± 8.7 years and 32.2 ± 13.3%, respectively. Additional comorbidities, not included in the EuroSCORE, were severe liver cirrhosis (2 patients), calcified ascending aorta (2 patients), and previous radiotherapy for mediastinal and breast cancer (2 patients). All patients underwent a

Comment

We recently introduced the TA-TAVI without angiography in our routine practice in order to prevent postoperative renal failure in high-risk patients requiring minimally invasive aortic valve surgery. In fact, it is well known that the extensive use of contrast medium in the elderly with multiple concomitant comorbidities can induce nephrotoxicity with subsequent renal insufficiency and (sometimes) need for transitory dialysis: such a scenario can cause prolonged hospital recoveries and negative

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