Percutaneous Transapical Left Ventricular Access to Treat Paravalvular Leak and Ventricular Septal Defect

Surgical transapical (TA) access is an established technique for structural heart (SH) procedures, but is associated with considerable morbidity. Percutaneous TA puncture provides direct access for SH procedures and may overcome the disadvantages of surgical access. This study sought to evaluate the safety of percutaneous TA left ventricular access for SH interventions.

We performed a retrospective analysis at a university hospital. Thirteen percutaneous TA procedures were performed on consecutive patients between January 2013 and July 2017 to provide LV access for transcatheter therapies. All procedures were performed under general anesthesia with three-dimensional transesophageal echocardiography guidance.

All TA punctures were successful. Delivery sheath sizes ranged from 5 Fr to 7 Fr. Eleven of the 13 TA sites were closed with a device. Total median procedural and fluoroscopy times were 106 minutes (interquartile range, 39-117 minutes) and 26.5 minutes (interquartile range, 8.3-43.8 minutes), respectively. The planned procedure was completed successfully in all cases. One access-site complication occurred, involving embolism of a duct occluder into the pleural space and extravasation from the apical puncture site. Hemostasis of the apex site was achieved immediately with placement of three vascular plugs from a femoral approach. Two patients died prior to discharge and neither death was related to a procedural complication. There were no significant pericardial effusions.

Percutaneous TA access can be achieved safely in most cases to provide access for transcatheter procedures with short procedure times. Device closure of the TA access site is reliable, with a low complication rate and no procedure-related mortality.