title: Alternative access options for transcatheter aortic valve replacement in patients with no conventional access and chest pathology.
abstract: OBJECTIVE
  Aortic stenosis is the most common valvular pathology in the elderly. Transcatheter aortic valve replacement has emerged as a safe and feasible alternative for high-risk patients. However, a significant number of patients are still not transcatheter aortic valve replacement candidates because of poor peripheral access and chest pathology. We report the use of alternative access options for such patients.
  
  
  METHODS
  Seven patients who had poor peripheral access and chest pathology had transcatheter aortic valve replacement using alternative access techniques. Five patients had the valve delivered by direct cannulation of the aorta via a mini-sternotomy, and 1 patient had the valve delivered via a mini-right thoracotomy. In 1 patient, the right subclavian artery was cannulated. Intraprocedural and 30-day outcome data were analyzed.
  
  
  RESULTS
  The mean age of patients was 85.00 ± 9.59 years, with a Society of Thoracic Surgeons score of 16.81% ± 6.87% and logistic European System for Cardiac Operative Risk Evaluation of 21.59% ± 8.46%. Procedural success was 100%. Procedural and 30-day mortality were zero. There were no access-related complications or neurologic events. Two patients had worsening renal function that did not require dialysis. All patients were discharged with a median hospital stay of 7 days. In our experience of 138 transapical or alternative access patients, 7 died (5%) and for 257 transfemoral patients, 1 died (0.4%).
  
  
  CONCLUSIONS
  Despite the high surgical risk of the study population, these techniques had excellent outcome with no mortality and acceptable morbidity. With the use of currently available technologies, these approaches are promising and offer alternative options in patients with no access and prohibitive chest pathology or pulmonary function.
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Division of Cardiovascular and Thoracic Surgery, Sultan Qaboos University Hospital, Muscat, Oman.
authors.forename: Adil H
authors.initials: AH
authors.lastname: Al Kindi
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Khaled F
authors.initials: KF
authors.lastname: Salhab
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Eric E
authors.initials: EE
authors.lastname: Roselli
authors.affiliation: Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Samir
authors.initials: S
authors.lastname: Kapadia
authors.affiliation: Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.
authors.forename: E Murat
authors.initials: EM
authors.lastname: Tuzcu
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio. Electronic address: svenssl@ccf.org.
authors.forename: Lars G
authors.initials: LG
authors.lastname: Svensson
mesh_terms: D000369:Aged, 80 and over; D001011:Aorta; D001024:Aortic Valve Stenosis / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D015897:Comorbidity; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D006801:Humans; D007902:Length of Stay; D008168:Lung / Q000503:physiopathology; D008171:Lung Diseases / Q000150:complications* / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy; D008297:Male; D010102:Oxygen Inhalation Therapy; D016491:Peripheral Vascular Diseases / Q000150:complications* / Q000175:diagnosis / Q000401:mortality; D012307:Risk Factors; D012720:Severity of Illness Index; D056346:Sternotomy; D013348:Subclavian Artery; D013908:Thoracotomy; D013997:Time Factors; D016896:Treatment Outcome
keywords: 28.1; 35.2; 35.3.5; AV; BAV; CPB; FEV1; ICU; SAVR; TAVR; TEE; aortic valve; balloon aortic valvuloplasty; cardiopulmonary bypass; forced expiratory volume in 1 second; intensive care unit; surgical aortic valve replacement; transcatheter aortic valve replacement; transesophageal echocardiography