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Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement
Published on: March 26, 2018
Sutureless aortic valve replacement: catheter-based transapical versus direct transaortic implantation
Mirko Doss1, Estelle Buhr, Anton Moritz
1Division of Cardiothoracic Surgery, Johann Wolfgang Goethe, University, Frankfurt/Main, Germany. mirko.doss@kgu.de
Insights
Transcatheter aortic valve implantation can compromise coronary perfusion. A sutureless transaortic valve replacement allows leaflet debridement, reducing risks and improving outcomes compared to transapical approaches.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Biomaterials Science
Background:
- Catheter-based aortic valve implantation leaves native calcified leaflets, potentially obstructing coronary arteries and the conduction system.
- This can limit the effective orifice area and lead to adverse perioperative events.
Purpose of the Study:
- To evaluate the perioperative outcomes of a self-expanding, sutureless aortic valve inserted via conventional aortotomy.
- To compare this approach with catheter-based transapical aortic valve implantation.
Main Methods:
- A total of 56 patients with aortic valve stenosis were included.
- 29 patients received transapical Edwards SAPIEN prosthesis; 27 received transaortic ATS 3F Enable prosthesis.
- The transaortic group underwent debridement of native leaflets using cardiopulmonary bypass (CPB).
Main Results:
- 30-day mortality was 11% in the transaortic group vs. 17% in the transapical group.
- The transaortic group had no paravalvular leaks, while the transapical group had four.
- Transapical implantation had higher rates of valve migration, heart block, and coronary obstruction.
Conclusions:
- Both sutureless aortic valve replacement devices can be safely implanted.
- The transaortic approach offers advantages, including native leaflet resection and reduced paravalvular leak rates.
- Elevated creatine kinase MB fraction was noted in the transapical group, with comparable inflammatory markers between groups.
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.
