Apical-access-related complications associated with trans-catheter aortic valve implantation.
OBJECTIVE
The left-ventricular trans-apical access has become well established for trans-catheter aortic valve implantation, especially for patients in whom a retrograde trans-arterial implantation is contraindicated. We report on the short- and long-term implications of the apical-access-site-specific complications.


METHODS
Between June 2007 and August 2010, 143 patients were scheduled for trans-apical aortic valve implantation (mean age 80 ± 6 years, n=116 females, mean logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) 21 ± 13%). The patients are followed up at 30 days, 6 months, and then annually.


RESULTS
Severe apical bleeding complications occurred in 10 patients (7%). In three of these patients, the procedure was terminated, and no valve was implanted. In the remaining, the bleeding was controlled with cardiopulmonary bypass support (n=3), via median sternotomy (n=1), or both (n=1) ± later re-exploration. Two additional patients required postprocedural re-exploration for apical bleeding. An apical pseudo-aneurysm developed in two patients (2%), one of whom was treated by surgical revision. Survival was significantly impaired when either apical bleeding, aneurysm, or re-exploration occurred (75% ± 0.082 survival at 30 days and 59% ± 0.122 at 1 year vs 94% ± 0.023 and 80% ± 0.043 in patients without apical complications, p=0.012). Twelve patients (8%) experienced secondary wound healing. An apical hypo- or akinesia was detected in 18/54 (33%) patients at 6 months' echocardiographic investigation, and in 11/30 (37%) 1 year after the procedure.


CONCLUSIONS
The trans-apical access for trans-catheter aortic valve implantation might be challenging in elderly patients with fragile tissue. Severe bleeding complications or aneurysm formation significantly impairs survival. The clinical impact of subsequent apical hypo- or akinesia has to be further followed up.
Clinic for Cardiovascular Surgery, German Heart Center Munich, Munich, Germany. bleiziffer@dhm.mhn.de
Sabine
S
Bleiziffer
Nicolo
N
Piazza
Domenico
D
Mazzitelli
Anke
A
Opitz
Robert
R
Bauernschmitt
Rüdiger
R
Lange
D000368:Aged; D000369:Aged, 80 and over; D017541:Aneurysm, False / Q000209:etiology; D001021:Aortic Valve / Q000601:surgery*; D016063:Blood Loss, Surgical; D005260:Female; D005500:Follow-Up Studies; D006322:Heart Aneurysm / Q000209:etiology; D006349:Heart Valve Diseases / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects* / Q000379:methods; D006801:Humans; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods; D019106:Postoperative Hemorrhage / Q000209:etiology; D012086:Reoperation