Expanding the eligibility for transcatheter aortic valve implantation the trans-subclavian retrograde approach using: the III generation CoreValve revalving system.
OBJECTIVE
Our aim was to assess the safety and feasibility of the retrograde trans-subclavian approach to transcatheter aortic valve implantation (TAVI) in selected high-risk patients with aortic stenosis (AS) and severe peripheral vasculopathy.


BACKGROUND
TAVI is an emerging therapeutic option to treat inoperable/high-risk patients affected by symptomatic AS. However, these patients are also often affected by severe iliac-femoral arteriopathy, rendering the transfemoral approach unemployable for percutaneous revalving procedure.


METHODS
From among those patients in our department between May 2007 and December 2008, who were refused surgical aortic valve replacement because of high surgical risk and were ineligible for transfemoral percutaneous aortic valve replacement, we scheduled 3 for TAVI by the subclavian approach. Procedures were performed by a combined team of cardiologists, cardiac surgeons, and anesthetists in the catheterization laboratory. The III generation CoreValve Revalving System (CoreValve Inc., Irvine, California) with an 18-F delivery system was introduced in all cases by the left subclavian artery.


RESULTS
Prosthetic valves were successfully implanted in all 3 cases, leading to a fall in transvalvular gradient without significant paravalvular regurgitation. No intraprocedural or periprocedural complications occurred. Two patients developed an atrioventricular block requiring the implantation of a permanent pacemaker. All patients were discharged in asymptomatic status, with good prosthesis performance. No adverse events occurred within the 3-month follow-up.


CONCLUSIONS
TAVI by subclavian retrograde approach seems safe and feasible in inoperable/high-risk patients with AS and peripheral vasculopathy, who are neither eligible for surgical valve replacement nor transfemoral percutaneous aortic valve implantation. Further studies are needed to evaluate the long-term efficacy of this new therapy.
Department of Interventional Cardiology, University of Padova, Padova, Italy. chiara_fraccaro@hotmail.com
Chiara
C
Fraccaro
Massimo
M
Napodano
Giuseppe
G
Tarantini
Valeria
V
Gasparetto
Gino
G
Gerosa
Roberto
R
Bianco
Raffaele
R
Bonato
Demetrio
D
Pittarello
Giambattista
G
Isabella
Sabino
S
Iliceto
Angelo
A
Ramondo
D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D001027:Aortography / Q000379:methods; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000295:instrumentation*; D005240:Feasibility Studies; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation*; D006801:Humans; D016015:Logistic Models; D008297:Male; D018579:Patient Selection; D016491:Peripheral Vascular Diseases / Q000150:complications* / Q000000981:diagnostic imaging; D011474:Prosthesis Design; D018570:Risk Assessment; D012720:Severity of Illness Index; D013348:Subclavian Artery / Q000000981:diagnostic imaging; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome