Alternative approaches for trans-catheter self-expanding aortic bioprosthetic valves implantation: single-center experience

Abstract Objective: Trans-catheter aortic valve implantation has emerged and rapidly gained credibility as a valuable alternative to treat patients with severe aortic stenosis and no surgical option; however, these patients are often affected also by severe iliac-femoral arteriopathy, rendering the transfemoral approach unemployable. From May 2008, 92 patients with severe, symptomatic aortic stenosis and no reasonable surgical option because of excessive risk underwent trans-catheter aortic valve implantation at our center. Eighty patients (34 male) with mean age 82 ± 8 years were eligible for CoreValve percutaneous femoral implantation. Twelve patients, mean age 81 ± 8 years, were excluded from percutaneous femoral CoreValve implantation because of iliac-femoral arteriopathy. Methods: These 12 patients underwent trans-catheter aortic valve implantation through the left axillary artery in six cases, the other six directly from the ascending aorta through a right anterior mini-thoracotomy. Procedures were performed by a combined team of cardiologists, cardiac surgeons, and anesthetists. Results: Procedural success was obtained in 11 cases; all these patients were discharged in asymptomatic status, with midterm good prosthesis performance. Three patients required the implantation of a permanent pacemaker. One patient needed a subclavian covered stent implantation to treat a post-implant artery dissection. One patient of the direct aortic access group was converted to the femoral approach due to an extremely fragile aortic wall, but died in the intensive care unit of abdominal aortic aneurysm rupture. All discharged patients improved their New York Heart Association (NYHA) functional class and functional capacity, and echocardiograms evidenced good valve performance at 2 years. Conclusions: Trans-catheter aortic valve implantation with surgical subclavian or direct aortic approach seems safe and feasible, offering a new attractive option to treat selected high-risk patients with severe aortic stenosis and peripheral vasculopathy, and has emerged as a valuable alternative route to trans-apical procedures.