Modified transapical-transcatheter aortic valve implantation

Abstract

Background and aim: Some transcatheter aortic valve implantation (TAVI) candidates present with ubiquitary arterial disease with massive calcification burden and stenoses in the whole arterial tree and cannot undergo any transvascular TAVI-approach. Moreover, a history of previous coronary surgery including LIMA-LITA in situ bypass grafting, previous carotid surgery or stenosis/occlusions, a concomitant porcelain aorta, Leriche syndrome, diverse other aortic diseases, arterial occlusions, or a chronic dialysis with arteriovenous shunt are common in such patients with end-stage peripheral artery disease, making even a minimal artery access impossible. For patients without arterial access or at very high risk for artery injury, we modified the transapical-TAVI method to ensure artery-no-touch-technique. We employed this technique in six patients without procedural and in-hospital complications.

Relevance for patients: A high-grade aortic stenosis is a serious disease. Untreated patients exhibit poor survival. Only surgery or TAVI is valid therapy concept for treatment. However, some patients can undergo neither surgery nor TAVI, because of an extensive surgical risk or inoperability, whereas at the same time, no arterial approaches are available due to extensive, end-stage panarteriopathy. For these high-specific patients, our modified, artery-no-touch-TA-TAVI is an appropriate method and can be safely used.

Keywords: end-stage panarteriopathy; modified; novelty; transapical-transcatheter aortic valve implantation.

Figure 1. Insertion of a femoral vein wire to serve as a “safety net”.

Figure 2. First 6-French sheath was used for positioning of a stiff guidewire and valve delivery sheath.

Figure 3. Second 6-French sheath, and a line (pigtail) as “safety net” and for angiographic visualization were performed through the left ventricle wall, approximately 1 cm beside the valve delivery sheath.

Figure 4. Final visualization of the aortic root, “dogboning” of the prosthesis and positioning of the pigtail into the left ventricle for fully prosthesis expansion.