title: Transseptal antegrade transcatheter aortic valve replacement for patients with no other access approach - a contemporary experience.
abstract: OBJECTIVE
  To assess the feasibility and outcomes in patients undergoing transvenous transseptal (TS) transcatheter aortic valve replacement (TAVR).
  
  
  BACKGROUND
  TS approach for TAVR was abandoned in favor of retrograde transfemoral, transaortic, or transapical approaches. TS TAVR may still be warranted in patients for whom no other approach is feasible.
  
  
  METHODS
  Observational consecutive case series at a single center, to evaluate technical outcomes in inoperable patients with aortic stenosis who had contraindications for other approaches and who underwent TAVR via a transvenous TS antegrade approach using the Edwards-Sapien (ES) valve.
  
  
  RESULTS
  Over a 4-month period, 9 patients underwent TS TAVR with 26 mm (n = 4) and 23 mm (n = 5) ES valves. Mean age was 84.5 ± 6.6 years and Society of Thoracic Surgeons predicted risk of mortality was 7.8 ± 2.8%. Specific contraindications for other access included iliofemoral arterial diameter <7 mm in 9 (100%), porcelain aorta in 6 (66%) patients, multiple (≥2) sternotomies in 2 (22%) patients, severe pulmonary disease in 3 (33%), extreme frailty in 1 (11%), spinal stenosis with impaired ability to rehabilitate postsurgery in 1 (11%) and apical left ventricular thrombus in 1 (11%) patient. Antegrade deployment of the ES prosthetic valve was technically feasible in 8 patients. Major bleeding occurred in 4 patients, two patients suffered acute kidney injury without need for dialysis and one patient required a permanent pacemaker. The median (25th, 75th percentiles) fluoroscopy time was 49 (34, 81) minutes and contrast volume was 150 (120, 225) ml. No patient had hemodynamically significant post-TAVR aortic insufficiency nor damage to the mitral valve. At 6 months follow-up, there were no cerebrovascular events or rehospitalizations and mean NYHA Class improved from 3.4 to 1.7.
  
  
  CONCLUSIONS
  The antegrade TS approach to TAVR is a technically feasible option for "no-access" patients. Prospective assessment of the safety and efficacy of this approach in the current era warrants further study.
authors.affiliation: Elaine and Sydney Sussman Cardiac Catheterization Laboratory, Cardiovascular Division, Depeartment of Medicine, University of Miami Hospital, Miller School of Medicine, Miami, Florida.
authors.forename: Mauricio G
authors.initials: MG
authors.lastname: Cohen
authors.forename: Vikas
authors.initials: V
authors.lastname: Singh
authors.forename: Claudia A
authors.initials: CA
authors.lastname: Martinez
authors.forename: Brian P
authors.initials: BP
authors.lastname: O'Neill
authors.forename: Carlos E
authors.initials: CE
authors.lastname: Alfonso
authors.forename: Pedro O
authors.initials: PO
authors.lastname: Martinezclark
authors.forename: Alan W
authors.initials: AW
authors.lastname: Heldman
authors.forename: William W
authors.initials: WW
authors.lastname: O'Neill
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D005240:Feasibility Studies; D005260:Female; D005431:Florida; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods* / Q000401:mortality; D006439:Hemodynamics; D006801:Humans; D008297:Male; D018579:Patient Selection; D011474:Prosthesis Design; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome
keywords: aortic stenosis; transcatheter aortic valve replacement; transseptal approach