Sutureless aortic valve replacement: catheter-based transapical versus direct transaortic implantation.

BACKGROUND AND AIM OF THE STUDY: Catheter-based aortic valve implantation leaves the calcified native leaflets in the aortic root. Upon valve deployment, the leaflets are pushed to the side, potentially compromising coronary perfusion, exerting pressure on the conduction system, and limiting the maximum effective orifice area. The study aim was to evaluate the perioperative outcome of an alternative self-expanding sutureless valve that is inserted via a conventional aortotomy, allowing for complete debridement of any calcified native aortic leaflets and annulus. METHODS: A total of 56 patients, all of which required bioprosthetic valve replacement for aortic valve stenosis, was included in the study. Twenty-nine patients underwent isolated catheter-based transapical aortic valve implantation using the Edwards SAPIEN prosthesis, while 27 patients underwent direct transaortic valve replacement, using the self-expandable ATS 3F Enable prosthesis. Implantation of the latter device utilized cardiopulmonary bypass (CPB), such that debridement of the calcified native leaflets was possible in all cases. The in-hospital echocardiographic findings and routine blood laboratory parameters of all patients were evaluated to determine the clinical outcome. RESULTS: The 30-day mortality was 17% in the transapical group and 11% in the transaortic group. Two conversions were performed in each group. One valve migration, one complete heart block and two cases of coronary obstruction occurred in the transapical group. The implantation times were 8 min in the transapical group and 10 min in the transaortic group. Four paravalvular leaks occurred in the transapical group, but none occurred in the transaortic group. CONCLUSION: Aortic valve replacement can be performed safely using either sutureless device. The transaortic approach has the additional advantage of allowing for the resection of native leaflets and for the performance of concomitant procedures. Laboratory investigations demonstrated an elevated creatine kinase MB fraction in the transapical group and comparable inflammatory parameters between groups, despite the use of CPB in the transaortic group.

Transcatheter-based aortic valve implantations at midterm: what happened to our initial patients?

BACKGROUND: This report analyzes a single institution's results with transapical aortic valve implantation (TAVI) from an initial series of patients over 5 years. METHODS: A series of 100 patients underwent TAVI at our institution between January 2005 and December 2008. The mean patient age was 85 ± 6 years. All patients had a high perioperative risk for aortic valve replacement (mean logistic EuroSCORE of 36% ± 12%; Society of Thoracic Surgeons [STS] score 16% ± 3%). Clinical and echocardiographic variables were entered prospectively into a database. Late follow-up for survival, clinical outcomes including the New York Heart (NYHA) Association functional class, and echocardiographic assessment was 100% complete. RESULTS: After a mean follow-up of 3.8 ± 2 years, overall mortality was 13% (n = 13/100), 30-day mortality was 8% (8/100), and late mortality was 5% (5/100). There were 2 perioperative repeated thoracotomies for bleeding, 2 intraoperative conversions, 1 prosthesis embolization, and 2 cases of impairment of coronary arteries. The causes of late mortality were cardiac failure (n = 2), respiratory failure (n = 1), renal failure (n = 1), and cancer (n = 1). At late follow-up there were no cases of endocarditis or stroke in any of the patients. None of the valves showed structural valve degeneration. NYHA functional class improved from 3.4 ± 0.4 before operation to 1.9 ± 0.5 at late follow-up (p = 0.02). Only 4 patients did not improve in functional class. CONCLUSIONS: Midterm outcomes after TAVI in high-risk patients at our institution show an improvement in functional capacity, with a good survival rate. Valve degeneration is not an issue at midterm follow-up.