The trans-apical approach for aortic valve implantation

Aims: We report on a minimally invasive approach through the left ventricular apex that allows accurate antegrade placement of a catheter deliverable aortic valve. Methods: 22 consecutive patients (83±6.4 years) were treated at our center. A limited anterolateral incision, in 5th intercostals space, was used to access the apex of the heart. The valve was crimped and placed into a 24 French sheath, and introduced into the left ventricle through purse string sutures. Fluoroscopy and transesophageal echo (TEE) was used to guide the catheter across the native valve and direct deployment of the stent at the level of the annulus. During deployment, the heart was unloaded with extracorporeal support (ECS), or with rapid ventricular pacing. The average logistic Euroscore predicted risk for mortality was 26±9%. Results: All valves were successfully deployed at the target. There were 2 valve related deaths and 3 non-procedure related deaths. There were two cases of conversion to open surgery. In one patient valve embolisation into the aortic arch occurred, and in another patient with a porcelain aorta, type A-dissection developed after balloon dilatation. In two patients, the left main stem was partially obstructed by the native valve and required stent angioplasty. On echocardiography, all valves showed good hemodynamic function with only minor paravalvular leakages. Conclusion: Initial results of the transapical approach are encouraging. Long term studies and randomized protocols will be required to further evaluate this procedure. Conclusion: Initial results of the transapical approach in high risk patients are encouraging.