HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Anson Cheung Samuel V. Lichtenstein Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ye, J. Articles by Webb, J. G. Search for Related Content PubMed PubMed Citation Articles by Ye, J. Articles by Webb, J. G. Related Collections Minimally invasive surgery Valve disease Related Article

J Thorac Cardiovasc Surg 2006;131:1194-1196
© 2006 The American Association for Thoracic Surgery

Brief Communication

Transapical aortic valve implantation in humans

Divisions of Cardiac Surgery and Cardiology, St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada

Received for publication November 28, 2005; revisions received January 4, 2006; accepted for publication January 12, 2006.

^_* Address for reprints: Samuel V. Lichtenstein, MD, PhD, Head, Cardiac Surgery, University of British Columbia, 1081 Burrard Street, Vancouver, BC, Canada V6Z 1Y6 (Email: slichtenstein{at}providencehealth.bc.ca).

Dr John Webb is a consultant at Edwards Lifesciences, Irvine, Calif.

Calcific aortic stenosis is the most common valvular disease affecting the elderly. Surgical aortic valve replacement improves symptoms and prognosis, but mortalities may be as high as 20% in elderly patients with left ventricular dysfunction. ¹ Catheter-based aortic valve implantation was recently achieved through antegrade venous ² and retrograde arterial routes. ³ We report on the deployment of an aortic valve prosthesis for severe aortic stenosis through the apex of the left ventricle in a 75-year-old patient without cardiopulmonary bypass or sternotomy.

Methods

Case Report
The procedure was approved by the Therapeutic Products Directorate, Department of Health and Welfare, Ottawa, Canada, for compassionate clinical use in patients deemed not to be candidates for surgery and without arterial access.

An emaciated, 52-kg, 75-year-old woman presented in congestive heart failure. Comorbidities included restrictive lung disease, severe psoriatic arthropathy, a calcified thoracic aorta, a large infrarenal aortic aneurysm, and bilateral aortoiliac disease. Cardiac catheterization revealed pulmonary hypertension and severe aortic stenosis with a mean gradient of 54 mm Hg and 0.4 cm² valve area. Echocardiograms demonstrated a mean gradient of 31 to 48 mm Hg, 0.7 to 0.8 cm² valve area, 23-mm ventriculo-annular diameter, and ejection fraction of 35% (Figure 1, A).

View larger version (62K): [in this window] [in a new window]   Figure 1. Transesophageal echocardiogram. Transesophageal echocardiogram (preoperative and postoperative long access). A, Long access—preoperative. Maximum opening of the thickened leaflets is severely restricted. Restrictive calcium can be visualized at the annulus and on the leaflets. B, Long access—postoperative. Stent valve is well positioned with unrestricted leaflet opening.

Procedure and Results

The procedure took place in the operating room under general anesthesia on October 27, 2005. A portable C-arm provided fluoroscopy. Aortography, through a right femoral arterial sheath, and transesophageal echocardiography were used to facilitate positioning of the prosthesis. The patient was premedicated with 300 mg clopidogrel, 81 mg aspirin, and vancomycin 1 g intravenously.

The pleural space was entered through a 5-to-8-cm sixth intercostal anterolateral thoracotomy. The pericardium over the apex of the left ventricle was identified and opened. To permit a 24F sheath, 2 paired orthogonal U-shaped sutures with pledgets were placed into the myocardium and passed through tensioning tourniquets. Temporary epicardial pacing wires were placed. Test pacing was performed to ensure reliable 1:1 capture at 150 to 200 beats/min and reduction in arterial pressure to less than 50 mm Hg. During valvuloplasty and prosthesis deployment, rapid pacing was used to minimize transaortic flow.

After 5000 units of heparin were administered, an 8F Angiocath was inserted through the apex of the left ventricle and a guidewire was passed through the aortic valve and down the descending aorta for stability. The Angiocath was exchanged for a 14F catheter, and a 20-mm balloon valvuloplasty was performed in preparation for valve deployment.

The Cribier valve (Edwards Lifesciences Inc, Irvine, Calif) is a 26-mm stainless-steel stent with an attached equine pericardial trileaflet valve and an annular fabric cuff. The valve was supplied sterile in glutaraldehyde and required onsite mechanical crimping onto a valvuloplasty balloon. A stiff 24F valve delivery sheath was introduced into the left ventricle and consciously kept in line with the aortic valve. The collapsed prosthetic valve was positioned by aortic root angiography (Figure 2, A) and echocardiography.

View larger version (73K): [in this window] [in a new window]   Figure 2. Ascending aortograms. Ascending aortograms (positioning of valve prosthesis before implantation and after prosthetic valve implantation). A, Positioning of valve prosthesis before implantation. A, Transesophageal echocardiogram probe to help with positioning at the aortic annulus and apical left ventricular deployment catheter and sheath. B, After prosthetic valve implantation. B, Prosthesis is positioned at the annulus and below the coronary ostia. There is no aortic insufficiency.

Echocardiography reported a resultant valve area of 1.9 cm² with a 3 mm Hg gradient (Figure 1, B). Aortic root angiography confirmed appropriate placement with no regurgitation (Figure 2, B).

Hemostasis was secured with previously placed pledgeted sutures. The pericardium was reapproximated to allow drainage and prevent myocardial herniation. A left chest tube drained 200 mL of serosanguineous fluid.

The patient was well and able to walk 3 days postprocedure without neurologic defects or shortness of breath. Repeat echocardiogram demonstrated a well-seated, normally functioning prosthesis without regurgitation. She was placed on 75 mg clopidogrel for 2 months and 81 mg aspirin daily. Because she lives alone, she was discharged 9 days postprocedure.

The 1-month postoperative echocardiogram demonstrated a valve area of 1.7 cm² with minimal paravalvular insufficiency. At approximately 2 months follow-up she remains in sinus rhythm, free of complications, and without any heart failure, functionally limited only by preexisting arthropathy.

Discussion

This case demonstrates the successful implantation of an aortic valve prosthesis for aortic stenosis through the apex of the left ventricle without sternotomy or the use of cardiopulmonary bypass in a human. The resultant hemodynamics and valve area are compatible with those achievable with open surgical replacement.

At present this procedure is offered to symptomatic patients deemed to be nonsurgical candidates without peripheral arterial access. With technologic advances, improved techniques, better understood selection criteria, and prosthesis durability, the indications may be expanded to high-risk surgical candidates.

This case demonstrates the feasibility of this approach and portends an evolving future for transchamber treatment of intracardiac pathology by cardiac surgeons.

See related editorial on page 941.

 

Acknowledgments

We thank Dr Todd Dewey for his advice and guidance in this case.

References

1. Alexander K, Ansstrom K, Muhlbaier LH, Grosswald RD, Smith PK, Jones RH, et al. Outcomes of cardiac surgery in patients age >80 years. results from the National Cardiovascular network. J Am Coll Cardiol 2000;35:731-738.[Abstract/Free Full Text]
   
2. Cribier A, Etchaninoff H, Bash A, Borrenstein N, Tron C, Bauer F, et al. Percutaneous trans-catheter implantation of an aortic valve prosthesis for calcific aortic stenosis; first human case description. Circulation 2002;106:3006-3008.[Abstract/Free Full Text]
   
3. Webb JG, Chandavimol M, Ricci DR, Carere RG, Thompson CR, Munt BI, et al. Percutaneous aortic valve implantation retrograde from the femoral artery. Circulation 2006;113:842-850.[Abstract/Free Full Text]
   

This article has been cited by other articles:

				J. L. Soon, J. Ye, S. V. Lichtenstein, D. Wood, J. G. Webb, and A. Cheung Transapical Transcatheter Aortic Valve Implantation in the Presence of a Mitral Prosthesis J. Am. Coll. Cardiol., August 9, 2011; 58(7): 715 - 721. [Abstract] [Full Text] [PDF]

				S. Bleiziffer, N. Piazza, D. Mazzitelli, A. Opitz, R. Bauernschmitt, and R. Lange Apical-access-related complications associated with trans-catheter aortic valve implantation Eur J Cardiothorac Surg, August 1, 2011; 40(2): 469 - 474. [Abstract] [Full Text] [PDF]

				P. Massabuau, N. Dumonteil, P. Berthoumieu, B. Marcheix, D. Duterque, G. Fournial, and D. Carrie Left-to-Right Interventricular Shunt as a Late Complication of Transapical Aortic Valve Implantation J. Am. Coll. Cardiol. Intv., June 1, 2011; 4(6): 710 - 712. [Full Text] [PDF]

				K. A. Horvath, D. Mazilu, O. Kocaturk, and M. Li Transapical aortic valve replacement under real-time magnetic resonance imaging guidance: experimental results with balloon-expandable and self-expanding stents Eur J Cardiothorac Surg, June 1, 2011; 39(6): 822 - 828. [Abstract] [Full Text] [PDF]

				G. Bruschi, F. De Marco, P. Fratto, J. Oreglia, P. Colombo, L. Botta, S. Klugmann, and L. Martinelli Alternative approaches for trans-catheter self-expanding aortic bioprosthetic valves implantation: single-center experience Eur J Cardiothorac Surg, June 1, 2011; 39(6): e151 - e158. [Abstract] [Full Text] [PDF]

				J. Leipsic, R. Gurvitch, T. M. LaBounty, J. K. Min, D. Wood, M. Johnson, A. M. Ajlan, N. Wijesinghe, and J. G. Webb Multidetector Computed Tomography in Transcatheter Aortic Valve Implantation J. Am. Coll. Cardiol. Img., April 1, 2011; 4(4): 416 - 429. [Abstract] [Full Text] [PDF]

				S. W. Grant, M. P. Devbhandari, A. D. Grayson, I. Dimarakis, I. Kadir, D. M. T. Saravanan, R. D. Levy, S. G. Ray, and B. Bridgewater What is the impact of providing a transcatheter aortic valve implantation service on conventional aortic valve surgical activity: patient risk factors and outcomes in the first 2 years Heart, October 15, 2010; 96(20): 1633 - 1637. [Abstract] [Full Text] [PDF]

				G. Bruschi, P. Fratto, F. De Marco, J. Oreglia, P. Colombo, L. Botta, A. Cannata, A. Moreo, B. De Chiara, F. Lullo, et al. The trans-subclavian retrograde approach for transcatheter aortic valve replacement: Single-center experience J. Thorac. Cardiovasc. Surg., October 1, 2010; 140(4): 911 - 915.e2. [Abstract] [Full Text] [PDF]

				D. R. Wong, J. Ye, A. Cheung, J. G. Webb, R. G. Carere, and S. V. Lichtenstein Technical considerations to avoid pitfalls during transapical aortic valve implantation J. Thorac. Cardiovasc. Surg., July 1, 2010; 140(1): 196 - 202. [Abstract] [Full Text] [PDF]

				J. Ye, A. Cheung, S. V. Lichtenstein, F. Nietlispach, S. Albugami, J. B. Masson, C. R. Thompson, B. Munt, R. Moss, R. G. Carere, et al. Transapical transcatheter aortic valve implantation: Follow-up to 3 years J. Thorac. Cardiovasc. Surg., May 1, 2010; 139(5): 1107 - 1113. [Abstract] [Full Text] [PDF]

				J. G. Webb and F. Nietlispach Chapter 39 Transcatheter aortic valve replacement Oxford Textbook of Interventional Cardiology, January 1, 2010; 1(1): med-9780199569083-chapter - med-9780199569083-chapter. [Abstract] [Full Text]

				A. Zierer, G. Wimmer-Greinecker, S. Martens, A. Moritz, and M. Doss Is transapical aortic valve implantation really less invasive than minimally invasive aortic valve replacement? J. Thorac. Cardiovasc. Surg., November 1, 2009; 138(5): 1067 - 1072. [Abstract] [Full Text] [PDF]

				J. Ye, J. G. Webb, A. Cheung, J.-B. Masson, R. G. Carere, C. R. Thompson, B. Munt, R. Moss, and S. V. Lichtenstein Transcatheter Valve-in-Valve Aortic Valve Implantation: 16-Month Follow-Up Ann. Thorac. Surg., October 1, 2009; 88(4): 1322 - 1324. [Abstract] [Full Text] [PDF]

				J.-B. Masson, J. Kovac, G. Schuler, J. Ye, A. Cheung, S. Kapadia, M. E. Tuzcu, S. Kodali, M. B. Leon, and J. G. Webb Transcatheter Aortic Valve Implantation: Review of the Nature, Management, and Avoidance of Procedural Complications J. Am. Coll. Cardiol. Intv., September 1, 2009; 2(9): 811 - 820. [Abstract] [Full Text] [PDF]

				D. Detaint, L. Lepage, D. Himbert, E. Brochet, D. Messika-Zeitoun, B. Iung, and A. Vahanian Determinants of Significant Paravalvular Regurgitation After Transcatheter Aortic Valve Implantation: Impact of Device and Annulus Discongruence J. Am. Coll. Cardiol. Intv., September 1, 2009; 2(9): 821 - 827. [Abstract] [Full Text] [PDF]

				J. G. Webb, L. Altwegg, R. H. Boone, A. Cheung, J. Ye, S. Lichtenstein, M. Lee, J. B. Masson, C. Thompson, R. Moss, et al. Transcatheter Aortic Valve Implantation: Impact on Clinical and Valve-Related Outcomes Circulation, June 16, 2009; 119(23): 3009 - 3016. [Abstract] [Full Text] [PDF]

				K.-E. Klaaborg, H. Egeblad, C.-J. Jakobsen, K. Terp, C. Lindskov, H. R. Andersen, and L. Thuesen Transapical Transcatheter Treatment of a Stenosed Aortic Valve Bioprosthesis Using the Edwards SAPIEN Transcatheter Heart Valve Ann. Thorac. Surg., June 1, 2009; 87(6): 1943 - 1946. [Abstract] [Full Text] [PDF]

				F. T. Billings IV, S. K. Kodali, and J. S. Shanewise Transcatheter Aortic Valve Implantation: Anesthetic Considerations Anesth. Analg., May 1, 2009; 108(5): 1453 - 1462. [Abstract] [Full Text] [PDF]

				R D Christofferson, S R Kapadia, V Rajagopal, and E M Tuzcu Emerging transcatheter therapies for aortic and mitral disease Heart, January 15, 2009; 95(2): 148 - 155. [Full Text] [PDF]

				J. Ye, A. Cheung, S. V. Lichtenstein, L. A. Altwegg, D. R. Wong, R. G. Carere, C. R. Thompson, R. R. Moss, B. Munt, S. Pasupati, et al. Transapical transcatheter aortic valve implantation: 1-year outcome in 26 patients. J. Thorac. Cardiovasc. Surg., January 1, 2009; 137(1): 167 - 173. [Abstract] [Full Text] [PDF]

				A. Sinhal, L. Altwegg, S. Pasupati, K. H. Humphries, M. Allard, P. Martin, A. Cheung, J. Ye, C. Kerr, S. V. Lichtenstein, et al. Atrioventricular Block After Transcatheter Balloon Expandable Aortic Valve Implantation J. Am. Coll. Cardiol. Intv., June 1, 2008; 1(3): 305 - 309. [Abstract] [Full Text] [PDF]

				J. G. Webb Percutaneous Aortic Valve Replacement Will Become a Common Treatment for Aortic Valve Disease J. Am. Coll. Cardiol. Intv., April 1, 2008; 1(2): 122 - 126. [Abstract] [Full Text] [PDF]

				S. H. Rahimtoola The Year in Valvular Heart Disease J. Am. Coll. Cardiol., February 19, 2008; 51(7): 760 - 770. [Full Text] [PDF]

				S. H. Rahimtoola The Year in Valvular Heart Disease J. Am. Coll. Cardiol., January 23, 2007; 49(3): 361 - 374. [Full Text] [PDF]

				F. Beyersdorf Transapical transcatheter aortic valve implantation Eur J Cardiothorac Surg, January 1, 2007; 31(1): 7 - 8. [Full Text] [PDF]

				J. Ye, A. Cheung, S. V. Lichtenstein, S. Pasupati, R. G. Carere, C. R. Thompson, A. Sinhal, and J. G. Webb Six-month outcome of transapical transcatheter aortic valve implantation in the initial seven patients Eur J Cardiothorac Surg, January 1, 2007; 31(1): 16 - 21. [Abstract] [Full Text] [PDF]

				S. V. Lichtenstein, A. Cheung, J. Ye, C. R. Thompson, R. G. Carere, S. Pasupati, and J. G. Webb Transapical Transcatheter Aortic Valve Implantation in Humans: Initial Clinical Experience Circulation, August 8, 2006; 114(6): 591 - 596. [Abstract] [Full Text] [PDF]

				S. V. Lichtenstein Closed heart surgery: Back to the future J. Thorac. Cardiovasc. Surg., May 1, 2006; 131(5): 941 - 943. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Anson Cheung Samuel V. Lichtenstein Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ye, J. Articles by Webb, J. G. Search for Related Content PubMed PubMed Citation Articles by Ye, J. Articles by Webb, J. G. Related Collections Minimally invasive surgery Valve disease Related Article