'Valve-on-a-Stick' Transaortic TAVI Offers Alternative to Transfemoral Route

Reed Miller

January 31, 2012

January 31, 2012 (Fort Lauderdale, Florida) — Surgeons in Europe are developing a transaortic approach to transcatheter aortic-valve implantation (TAVI), and so far the results suggest this more direct approach will be an important alternative for TAVI patients unsuitable for the transfemoral approach.

Here at the Society of Thoracic Surgeons (STS) 2012 Annual Meeting, Dr Vinayak Bapat(St Thomas Hospital, London, UK)presented resultsfrompatients who received a Sapien (Edwards Lifesciences) implant via a transaortic approach [1]. Dr Neal Moat (Royal Brompton & Harefield Trust, London, UK) presented results from patients implanted transaortically with the CoreValve (Medtronic) [2].

 

  Medtronic CoreValve system, direct aortic access Source: Medtronic

Bapat said that his center started trying the transaortic approach in surgery-ineligible patients with inaccessible femoral arteries who were also unsuitable for the transapical approach, often because of poor respiratory function. But now, his center is among a few in Europe that considers the transaortic approach before the transapical approach for patients unsuitable for the transfemoral approach, Bapat said.

Moat told heartwire that a major advantage of the transaortic approach over the transapical approach is that the incisions are less painful for the patient. Also, intervention through the left ventricle has well-known risks, including bleeding and late aneurysm formation. "Cardiac surgeons, over the past 30 or 40 years, have tried to steer clear of the left ventricular apex. It's just not an intuitive thing to do."

However, the transaortic approach is similar to other procedures cardiac surgeons are familiar with. The valve is inserted on the catheter through an upper ministernotomy or a right anterior minithoracotomy and then through a small hole in the aorta just like the one surgeons make to cannulate the aorta for a heart-lung bypass. The CoreValve can also be implanted through a subclavian incision. It allows the surgeon to insert the valve on a straight line from the incision to the annulus. "This procedure is like what [surgeons] do every day," Bapat said. The procedure is imaged with fluoroscopy and transesophageal echo.

Moat explained to heartwire :"The further away you are from the aorta, the more difficult it is. Transfemorally, you have a lot of curves, which gives a lag in the system." But with the transaortic approach, the operator is "in proximity to the valve with clear control of the device. It's a bit like having a valve on a stick . . . with very precise control of the positioning of the device."

Low Stroke Risk in Early Transaortic Sapien Implants

At the STS conference, Bapat presented results from 157 patients transaortically implanted with a Sapien at 10 European centers. The average age of the patients was 80, about a quarter had diabetes, nearly 40% had peripheral vascular disease, and three-quarters had hypertension. Their mean valve area was 0.60 cm2 and mean gradient was 67 mm Hg.

Procedural success was achieved in all patients. The overall 30-day mortality was 7%, but Bapat stressed that none of the patients in the series suffered postoperative stroke or persistent AV block. There were also no cases of valve migration, conversion to open surgery, or access-site complications.

The postprocedural mean and peak gradients were 6.2 and 11 mm Hg, respectively, and none of the patients had more than grade 2 aortic regurgitation at discharge. As might be expected for patients of this high risk, about 5% of patients had renal failure, and a major vascular complication was observed in 1.2%, he said.

CoreValve Data Show Dramatic Learning Curve

Moat presented results from 115 patients transaortically implanted with a CoreValve at 19 European centers between June 2008 and the end of 2011.

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