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A) CT angiogram of the abdominal aorta and the iliac/femoral arteries of the first patient. Note the excessive wall calcification, as well as the high grade bilateral stenosis at the aortic bifurcation (arrow). (B) CT of the first patient, showing severe calcification of the ascending aorta starting 7 cm above the aortic valve level. The left subclavian artery is also unsuitable for TAVI. (C) CT angiogram of iliac/femoral arteries (right/left) of the second patient. The locations most severely stenosed are shown with an arrow (left iliac artery minimum diameter 4.5 mm, right iliac artery minimum diameter 3.4 mm). Note also the severe diffuse vessel calcification. (D) CT angiogram of the second patient, showing the origin of the left subclavian artery from the aortic arch (minimum diameter 4.5 mm).
Source publication
The aim of this study was to test the safety and efficacy of the retrograde, minimally invasive, "transaortic" approach of transcatheter aortic valve implantation (TAVI) using the Medtronic CoreValve prosthesis (Medtronic, Minneapolis) as an alternative minimally invasive surgical access route.
TAVI is today recognized as an established percutaneou...
Contexts in source publication
Context 1
... on the above findings, it was decided to pro- ceed with transcatheter aortic valve implantation of a CoreValve prosthesis, as she was considered of very high operative risk (logistic EuroScore 49%, STS score 27%) for conventional surgery. However, neither a transfemoral nor a trans-subclavian approach were pos- sible. (Fig. 1A) We therefore chose to proceed with the transaortic procedure. On CT the annulus width measured 26 mm, making TAVI with the Edwards- Sapien prosthesis not possible, with severe calcification of the ascending aorta starting 7 cm above the aortic valve level (Fig. ...
Context 2
... However, neither a transfemoral nor a trans-subclavian approach were pos- sible. (Fig. 1A) We therefore chose to proceed with the transaortic procedure. On CT the annulus width measured 26 mm, making TAVI with the Edwards- Sapien prosthesis not possible, with severe calcification of the ascending aorta starting 7 cm above the aortic valve level (Fig. ...
Context 3
... patient was considered high risk for conven- tional open heart surgical aortic valve replacement (logistic EuroScore 53%, STS score 47%). Neverthe- less, the peripheral vessels were not of sufficient size (left iliac artery minimum diameter 4.5 mm, right iliac artery minimum diameter 3.4 mm) and were also severely calcified (Fig. 1C). The left subclavian artery was also unsuitable for a transaxillary approach, as its minimum diameter was only 4.5 mm (Fig. 1D). On CT the annulus width measured 22 mm, without severe calcification of the ascending aorta. The transapical approach was found inappropriate, due to scarring and surgical adhesions of the anterior thoracic ...
Context 4
... EuroScore 53%, STS score 47%). Neverthe- less, the peripheral vessels were not of sufficient size (left iliac artery minimum diameter 4.5 mm, right iliac artery minimum diameter 3.4 mm) and were also severely calcified (Fig. 1C). The left subclavian artery was also unsuitable for a transaxillary approach, as its minimum diameter was only 4.5 mm (Fig. 1D). On CT the annulus width measured 22 mm, without severe calcification of the ascending aorta. The transapical approach was found inappropriate, due to scarring and surgical adhesions of the anterior thoracic ...
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Background:
Chronic liver disease is traditionally conceived as a risk factor for cardiovascular surgery. Transcatheter aortic valve implantation (TAVI) has recently burgeoned to precede surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis at intermediate to high surgical risk. The evidence regarding TAVI in the patient...
Surgical replacement of the aortic valve is the standard therapy for severe aortic valve stenosis. However, it is generally associated with increased mortality and morbidities in older individuals. Transcatheter aortic valve implantation (TAVI) is a less invasive procedure and has shown similar clinical outcomes as surgical treatment in elderly pat...
Transcatheter aortic valve implantation (TAVI) has emerged for treating aortic stenosis in patients who are poor candidates for surgical aortic valve replacement. Currently, the balloon-expandable Edwards Sapien valve-which is usually implanted via a transfemoral or transapical approach-and the self-expanding CoreValve ReValving system-which is des...
Aims:
Multislice computed tomography (MSCT) is recommended for annular sizing prior to transcatheter aortic valve implantation (TAVI), but it remains unclear whether systolic or diastolic reconstructions should be used and whether the effective annular diameter should be derived by area or perimeter. In this study these different approaches were c...
Objective
A paucity of data exists on how transcatheter aortic valve implantation (TAVI) practice has evolved in Ireland. This study sought to analyse temporal trends in patient demographics, procedural characteristics, and clinical outcomes at an Irish tertiary referral centre.
Methods
The prospective Mater TAVI database was divided into time ter...
Citations
... Transaortic TAVI with both Edwards Sapien and Medtronic Evolut® devices (Medtronic, Minnesota, USA) has been described previously. [4][5][6][7] In this case report, we present the first transaortic implantation of an Acurate Neo 2 system (Boston Scientific Corp., Natick, MA, USA) to treat a patient with severe AS and unfavourable transfemoral and trans-subclavian access. ...
Background
In more than 90% transcatheter aortic valve implantation is performed via transfemoral access. Alternative access routes are necessary for patients with unfavourable femoral arteries.
Case summary
We report of a 68-year-old female with symptomatic severe aortic stenosis who in whom surgical aortic valve replacement was prohibited due to her severe comorbidities. Both femoral arteries and both subclavian arteries were unsuitable for TAVI access. Surgical aortic valve replacement and transapical TAVI were deferred due to extremely high operative risk and very low originating left coronary artery of 7 mm from annulus. Hence, we decided to implant a self-expanding TAVI device with low risk of coronary obstruction (Acurate Neo 2 prosthesis) via transaortic approach, which to our knowledge is the first case worldwide.
Conclusion
The present case demonstrates the feasibility of implanting Acurate Neo2 system via transaortic approach when certain key points are respected. Transaortic TAVI with Acurate Neo 2 offers a minimally invasive treatment of high operative risk patients with low originating coronary arteries.
... A preoperative multislice computed tomography scan (MSCT) is generally performed to assess the valve complex, define the access site, and avoid complications [6,7] (Figure 1). So far, several alternative access routes for antegrade or retrograde TAVI procedures have been described, namely the transfemoral, transaortic, transapical, transcarotid and transaxillary access routes [8][9][10][11]. The transfemoral (TF) access route is considered the gold standard approach for TAVI; however, it can be precluded by unfavorable anatomical characteristics such as calcification, tortuosity, and peripheral artificial graft. The TF approach is usually unsuitable in 10-15% of patients who are candidates for TAVI [12]. ...
Background: The aim of our study was to determine the feasibility and efficacy of transaxillary (TAX) TAVI in patients not eligible for the transfemoral route. Methods: This is a retrospective study of a single center. We analysed 262 patients treated with TAVI. In 17 patients (6.5%), the procedure was performed with the TAX approach. Procedural and hospital data, 30-day safety, and clinical efficacy were assessed and compared between the transfemoral and TAX groups. Results: In the TAX groups, we found a higher prevalence of men (p = 0.001), smokers (p = 0.033), and previous strokes (p = 0.02). The EUROSCORE II was higher in the TAX group (p = 0.014). The success rate of the device was 100%. TAX was associated with a longer procedure time (p = 0.001) and shorter median device time (p = 0.034) in minutes. Patients treated with TAX had a longer hospital stay (p = 0.005) and higher overall bleeding rate (p = 0.001). Peripheral neurological complications were more frequent with TAX (p = 0.001), which almost completely resolved by 30 days. Conclusions: TAX TAVI is safe and effective and should be considered as a second choice when transfemoral TAVI is not feasible due to severe comorbidities.
... Всички тези и много други данни получени от големи нерандомизирани изпитвания са предпоставка за преразглеждане на препоръките за TAVI на кардиологичните дружества [8,9,10,11]. В препоръките за клапни сърдечни заболявания на Европейското дружество по кардиология (ESC) от 2021 г., е въведена нова препоръка, според която не-TF съдов достъп при TAVI може да бъде обмислен при пациенти, които са иноперабилни и с неподходящ TF достъп [7]. ...
We report a case of an 80-years–old patient with a severe, symptomatic aortic valve stenosis and history of ischemic heart disease, previously treated by coronary artery bypass graft surgery. The patient was contraindicated for conventional surgical aortic valve replacement (SAVR) due to advanced age and underlying comorbidity, therefore transcatheter aortic valve implantation (TAVI) has been offered. The access options for the procedure were restricted by the underlying generalized atherosclerosis process causing peripheral vessel disease. We have chosen transaortic access for the patient which in that case was the only possible option. The transaortic valve implantation was successful with satisfactory hemodynamic results, improvement in functional class heart failure of the patient and preserving the function and anatomy of the coronary artery bypass graft. This case report demonstrates that the lack of favorable transfemoral access for TAVI should not be a limitation by itself for the procedure, rather than be stimulus for searching and using new and alternative access for it.
... Depending on the anatomical position of the aorta, the transaortic access is performed either through a right anterior mini-thoracotomy in case of a right-sided ascending aorta or patent bypass grafts or through a median hemi-sternotomy in case of deep intrathoracic location or severe lung disease [86]. A minimum puncture to native aortic annulus distance of 8 mm for the Edwards Sapien 3 valve and 6mm for the Medtronic CoreValve is required [37,87]. ...
Transcatheter aortic valve replacement (TAVR) has replaced surgical aortic valve replacement as the new gold standard in elderly patients with severe aortic valve stenosis. However, alongside this novel approach, new complications emerged that require swift diagnosis and adequate management. Vascular access marks the first step in a TAVR procedure. There are several possible access sites available for TAVR, including the transfemoral approach as well as transaxillary/subclavian, transcarotid, transapical, and transcaval. Most cases are primarily performed through a transfemoral approach, while other access routes are mainly conducted in patients not suitable for transfemoral TAVR. As vascular access is achieved primarily by large bore sheaths, vascular complications are one of the major concerns during TAVR. With rising numbers of TAVR being performed, the focus on prevention and successful management of vascular complications will be of paramount importance to lower morbidity and mortality of the procedures. Herein, we aimed to review the most common vascular complications associated with TAVR and summarize their diagnosis, management, and prevention of vascular complications in TAVR.
... Access involving the ascending aorta was developed as a means of countering the potential complications related to left ventricular apical access in elderly and frail patients, and the TAo route was first described in 2010. 20 A partial upper sternotomy is performed, extended down to the second or third right intercostal space, although sternalsparing approaches have been described, such as an incision through the suprasternal notch. General anesthesia is required. ...
... Moreover, 30-day mortality has been shown to be low (6.7%), despite this reflecting an innately high-risk TAVR cohort, as mentioned above. 2 Furthermore, direct access obviates the risk of dislodging atherosclerotic plaques, which is a risk in using peripheral access sites. Thus, direct access remains an important option in performing TAVRs in contemporary practice, although, of the two, the direct aortic route is preferred, both due to familiarity to cardiac surgeons as well as the options of using a wider array of valves, the details of which shall be discussed later. ...
Over the last two decades, the medical community witnessed an outstanding and accelerated development on minimally invasive therapies. The definition of what constitutes large bore access is subject to discussion, however within the field it is generally accepted to reflect a catheter diameter exceeding 8‐French. We sought in this review to explore the evolution, characteristics and vascular compatibility of the current commercially available devices, analyze the devices along with access site‐specific complications rates and finally review the present methods for percutaneous vascular closure.
... The goal of this procedure is minimizing surgical trauma by avoiding sternotomy, aortotomy, cardiopulmonary bypass (CPB) and by implanting the prosthetic valve on beating heart, thereby avoiding cardiac arrest, in order to decrease perioperative risks and improve patient outcomes [7] . Depending on patient characteristics, TAVR can be performed using different access sites including transfemoral (TF), trans-subclavian/trans-axillary, transaortic, or transapical approaches [8][9][10] . The most commonly used approach to performing TAVR is the TF approach by retrograde deployment of the valve passing through the ascending aorta. ...
Aortic valve replacement (AVR) is the current standard treatment for severe aortic stenosis, nonetheless, many patients are not suitable to AVR because of high risk related to advanced age, impaired cardiac function, or comorbidities. Given these considerations, transcatheter aortic valve replacement or implantation (TAVR or TAVI) has emerged in the last decade as an alternative to surgery and has become the treatment of choice for severe aortic stenosis in patients with prohibitive surgical risk. In the context of this kind of hybrid procedure, the anesthesiologist plays a central role because the choice of anesthetic technique is strongly related to clinical features of the patients and technical considerations, which must be discussed collegially with the surgeons. The choice of anesthesiologic management is different among hospitals, but it is generally based on preoperative comorbidities, procedural approach used for TAVR and even hospital logistic. Some centers used to perform TAVR under general anesthesia (GA), some else under local anesthesia plus sedation (LAS), some of them start their TAVR program under GA, but convert in LAS when the team get enough experience. Also, anesthesiologists involved in TAVR procedures must be part of a “heart team”, and should be confident with anesthesia for cardiovascular surgery, mechanical circulatory support, and with transesophageal echocardiography. The aim of this article is to provide a general overview about anesthetic techniques in TAVR and to evaluate pathways for future researches.
... Transaortik yaklaşımda ise parsiyel sternotomi ile asendan aort aracığıyla aort kapağa ulaşılmaktadır. [22][23][24] ...
ÖZET
Ölüm nedenleri arasında ilk sırada dolaşım sistemi hastalıkları yer almaktadır. Bu hastalıklar içerisinde iskemik kalp hastalıkları ilk sırada olmasına rağmen, kalp kapak hastalıklarının görülme sıklığının da oldukça yüksek olduğu bilinmektedir. Bu nedenle günümüzde kalp kapak cerrahisine duyulan ihtiyaç da oldukça fazladır. Kalp ameliyatları arasında, koroner arter baypas greft cerrahisi sonrası ikinci sırada yer alan kalp kapak ameliyatları hastalıklı kapağın onarılması ya da değiştirilmesi uygulamalarını içermektedir. Kalp kapak cerrahisi sonrası verilen hemşirelik bakımı oldukça karmaşık ve önemli olup, hastanın tüm sistem fonksiyonlarını değerlendirerek planlama ve uygulama yapmayı gerektirmektedir. Ayrıca bakım kapak cerrahisi sonrası gelişebilecek komplikasyonların takibini, tedavisini ve hastanın eğitimini de içermektedir.
ABSTRACT
Circulatory system diseases are at the first place among causes of death. Although ischemic heart disease is at the first rank in these diseases, it is known that the incidence of heart valve diseases is very high. So, today the need for heart valve surgery is also high. Heart valve operations, which rank second after coronary artery bypass graft operations among heart surgeries, include repair or replacement of the diseased valve. In this article, we discussed aortic, pulmonary, mitral and tricuspid valve diseases, surgical valve therapies and postoperative care after valve surgery. Nursing care after heart valve surgery is very complex and important and, it requires planning and implementation by evaluating all system functions of the patient. In addition, care must include following and treating of complications after heart valve surgery and patient training.
... Identifying severe arterial calcifications, both longitudinal and circumferential, depicting vascular disease or variations, determining the presence of thrombi, and/or dissections and of rather unfavorable morphologies of the access arterial vessels (elongation, tortuosity, significant angulation) are parameters that correlate with a higher complication risk. 41e44 The preferred implantation root is the trans-femoral; if not possible, trans-subclavian, 45 trans-apical, or trans-aortic 46 can be used alternatively. MSCT vessel mapping using curved MPR is performed, with creation of perpendicular axial images, to have a reliable estimation of minimal patent lumen diameters. ...
Aortic valve stenosis (AS) is the commonest valvular heart disease among elderly. Trans-catheter aortic valve implantation (TAVI) has become an established and effective alternative therapeutical procedure for inoperable and high risk patients with symptomatic AS. The procedural success is greatly dependent on a thorough pre- TAVI imaging screening. This requires a comprehensive and multi-modality approach, in which multi-slice computed tomography (MSCT) is the cornerstone in the selection of eligible patients, in choosing the appropriate prosthesis and its size, as well as in mapping the safest access route for the intervention. Based on our experience of more than 400 TAVI procedures and many more MSCT for screening purposes, we provide clinical and technical details on the use of MSCT pre-TAVI as well a brief review of the so far knowledge.
... These include the transfemoral (TF), trans-subclavian/trans-axillary, transaortic, or transapical approaches. [6][7][8] The preferred approach to performing a TAVR is the retrograde TF approach as it is the least invasive, and it continues to be the approach used in the majority of patients without severe vascular disease. 9 In TF TAVRs, the artery is cannulated, with the retrograde deployment of the valve passing through the ascending aorta. ...
