title: Transapical access closure: the TA PLUG device.
abstract: OBJECTIVE
  Percutaneous closure of the transapical (TA) access site for large-calibre devices is an unsolved issue. We report the first experimental data on the TA PLUG device for true-percutaneous closure following large apical access for transcatheter aortic valve implantation.
  
  
  METHODS
  The TA PLUG, a self-sealing full-core closure device, was implanted in an acute animal study in six pigs (60.2 ± 0.7 kg). All the pigs received 100 IU/kg of heparin. The targeted activated clotting time was left to normalize spontaneously. After accessing the left ventricular apex with a 39 French introducer, the closure plug device was delivered with a 33 French over-the-wire system under fluoroscopic guidance into the apex. Time to full haemostasis as well as rate of bleeding was recorded. Self-anchoring properties were assessed by haemodynamic push stress under adrenalin challenge. An additional feasibility study was conducted in four pigs (58.4 ± 1.1 kg) with full surgical exposure of the apex, and assessed device anchoring by pull-force measurements with 0.5 Newton (N) increments. All the animals were electively sacrified. Post-mortem analysis of the heart was performed and the renal embolic index assessed.
  
  
  RESULTS
  Of six apical closure devices, five were correctly inserted and fully deployed at the first attempt. One became blocked in the delivery system and was placed successfully at the second attempt. In all the animals, complete haemostasis was immediate and no leak was recorded during the 5-h observation period. Neither leak nor any device dislodgement was observed under haemodynamic push stress with repeated left ventricular peak pressure of up to 220 mmHg. In the feasibility study assessing pull-stressing, device migration occurred at a force of 3.3 ± 0.5 N corresponding to 247.5 mmHg. Post-mortem analyses confirmed full expansion of all devices at the intended target. No macroscopic damage was identified at the surrounding myocardium. The renal embolic index was zero.
  
  
  CONCLUSIONS
  True-percutaneous left ventricular apex closure following large access is feasible with the self-sealing TA PLUG. The device allows for immediate haemostasis and a reliable anchoring in the acute animal setting. This is the first report of a true-percutaneous closure for large-calibre transcatheter aortic valve implantation access.
authors.affiliation: Department of Cardiovascular Surgery, Swiss Cardiovascular Centre, University Hospital of Bern, Bern, Switzerland.
authors.forename: Henriette
authors.initials: H
authors.lastname: Brinks
authors.forename: Fabian
authors.initials: F
authors.lastname: Nietlispach
authors.forename: Volkhard
authors.initials: V
authors.lastname: Göber
authors.forename: Lars
authors.initials: L
authors.lastname: Englberger
authors.forename: Peter
authors.initials: P
authors.lastname: Wenaweser
authors.forename: Bernhard
authors.initials: B
authors.lastname: Meier
authors.forename: Thierry
authors.initials: T
authors.lastname: Carrel
authors.forename: Christoph
authors.initials: C
authors.lastname: Huber
mesh_terms: D000818:Animals; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000295:instrumentation; D062906:Cardiac Catheters; D004867:Equipment Design; D005240:Feasibility Studies; D005548:Foreign-Body Migration / Q000209:etiology; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D006439:Hemodynamics; D006470:Hemorrhage / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D006489:Hemostatic Techniques / Q000295:instrumentation*; D008422:Materials Testing; D023421:Models, Animal; D011677:Punctures; D013314:Stress, Mechanical; D013552:Swine; D013997:Time Factors
keywords: Apex; Closure device; Percutaneous; Sutureless; Transapical; Transcatheter; Transcatheter aortic valve implantation