title: Fluoroscopy use and left anterior descending artery angiography to guide transapical access in patients with prior cardiac surgery.
abstract: BACKGROUND
  Patients with severe aortic stenosis (AS) and prior cardiac surgery undergoing aortic valve replacement (AVR) are at high risk. Transapical AVR might reduce the risk in patients not suitable for the transfemoral approach. We aimed to describe the fluoroscopy and left anterior descending artery (LAD) angiography guidance technique for transapical AVR access and the initial related procedural results.
  
  
  METHODS
  Patients with severe AS and prior cardiac surgery undergoing transapical AVR using LAD angiographic-guided apical puncture were analyzed (n=9). Additional guidance was added to the standard technique as follows. Minithoracotomy was performed at the level of the intercostal space in closer relationship to the apex identified by fluoroscopy. LAD angiography was performed at the time that the area of interest was recognized by radiopaque marker to ensure puncture lateral to the LAD. Apical needle puncture was performed under fluoroscopy guidance directed towards the aortic root.
  
  
  RESULTS
  The population had a mean age of 83 years and was more frequently male (89%) with a high-risk profile (mean Society of Thoracic Surgeons score of 11%). Two patients received the 23-mm Edwards SAPIEN valve, and seven patients received the 26-mm SAPIEN device. All nine patients underwent successful implantation of transcatheter aortic valves with virtual abolishment of transaortic gradient, without procedural complications.
  
  
  CONCLUSIONS
  Fluoroscopy and angiography for guidance of the transapical approach facilitate a safe and rapid access to the apex, insuring no risk of damage to the LAD or to large diagonals.
authors.affiliation: Division of Cardiology, Department of Cardiac Surgery, Washington Hospital Center, Washington, DC 20010, USA
authors.forename: Gabriel
authors.initials: G
authors.lastname: Maluenda
authors.forename: Itsik
authors.initials: I
authors.lastname: Ben-Dor
authors.forename: Israel M
authors.initials: IM
authors.lastname: Barbash
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Corso
authors.forename: Steven W
authors.initials: SW
authors.lastname: Boyce
authors.forename: Lowell F
authors.initials: LF
authors.lastname: Satler
authors.forename: Augusto D
authors.initials: AD
authors.lastname: Pichard
authors.forename: Ron
authors.initials: R
authors.lastname: Waksman
mesh_terms: D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging* / Q000601:surgery; D006328:Cardiac Catheterization / Q000379:methods / Q000706:statistics & numerical data; D017023:Coronary Angiography / Q000706:statistics & numerical data*; D005260:Female; D005471:Fluoroscopy / Q000706:statistics & numerical data*; D005500:Follow-Up Studies; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D008297:Male; D011300:Preoperative Care / Q000379:methods* / Q000706:statistics & numerical data; D015203:Reproducibility of Results; D012189:Retrospective Studies