The trans-subclavian retrograde approach for transcatheter aortic valve replacement: single-center experience.
OBJECTIVE
Aortic valve disease is the most common acquired valvular heart disease in adults. With the increasing elderly population, the proportion of patients with symptomatic aortic stenosis who are unsuitable for conventional surgery is increasing. Transcatheter aortic valve implantation has rapidly gained credibility as a valuable alternative to surgery to treat these patients; however, they often have severe iliac-femoral arteriopathy, which renders the transfemoral approach unusable. We report our experience with the trans-subclavian approach for transcatheter aortic valve implantation using the CoreValve (Medtronic CV Luxembourg S.a.r.l.) in 6 patients.


METHODS
In May 2008 to September 2009, 6 patients (mean age of 82 ± 5 years), with symptomatic aortic stenosis and no reasonable surgical option because of excessive risk, were excluded from percutaneous femoral CoreValve implantation because of iliac-femoral arteriopathy. These patients underwent transcatheter aortic valve implantation via the axillary artery. Procedures were performed by a combined team of cardiologists, cardiac surgeons, and anesthetists in the catheterization laboratory. The CoreValve 18F delivery system was introduced via the left subclavian artery in 6 patients, 1 with a patent left internal thoracic to left anterior descending artery graft.


RESULTS
Procedural success was obtained in all patients, and the mean aortic gradient decreased 5 mm Hg or less immediately after valve deployment. One patient required implantation of a permanent pacemaker. One patient required a subclavian covered stent implantation to treat a postimplant artery dissection associated with difficult surgical hemostasis. One patient was discharged in good condition but died of pneumonia 40 days after the procedure. All patients were asymptomatic on discharge, with good mid-term prosthesis performance.


CONCLUSIONS
Transcatheter aortic valve implantation via a surgical subclavian approach seems safe and feasible, offering a new option to treat select, inoperable, and high-risk patients with severe aortic stenosis and peripheral vasculopathy.
Bruschi
Giuseppe
G
A De Gasperis Cardiology and Cardiac Surgery Department, Niguarda Ca' Granda Hospital, Milan, Italy. giuseppe.bruschi@fastwebnet.it
Fratto
Pasquale
P
De Marco
Federico
F
Oreglia
Jacopo
J
Colombo
Paola
P
Botta
Luca
L
Cannata
Aldo
A
Moreo
Antonella
A
De Chiara
Benedetta
B
Lullo
Francesca
F
Paino
Roberto
R
Martinelli
Luigi
L
Klugmann
Silvio
S
D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000503:physiopathology*; D001024:Aortic Valve Stenosis / Q000503:physiopathology / Q000628:therapy*; D001366:Axillary Artery / Q000000981:diagnostic imaging; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000295:instrumentation; D005240:Feasibility Studies; D005260:Female; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D006439:Hemodynamics; D006801:Humans; D007558:Italy; D008297:Male; D015641:Radiography, Interventional; D020127:Recovery of Function; D012720:Severity of Illness Index; D013348:Subclavian Artery / Q000000981:diagnostic imaging; D013997:Time Factors; D016896:Treatment Outcome