title: Transcatheter aortic valve replacement: experience with the transapical approach, alternate access sites, and concomitant cardiac repairs.
abstract: OBJECTIVE
  Transapical transcatheter aortic valve replacement (TA-TAVR) is a viable treatment option for selected high-risk elderly patients. We analyzed the 30-day mortality and perioperative complications, focusing on the "learning curve" since our first TA procedure in 2007. We also introduce unique cases, demonstrating new possibilities for alternate access sites and concurrent cardiac interventions using the apical approach.
  
  
  METHODS
  From February 2007 to May 2013, 150 patients underwent TA-TAVR (mean age, 81.4 ± 7 years; mean Society of Thoracic Surgeons score, 9.8±3.5). We compared 2 groups (group A, n=65, procedures from February 2007 to December 2010; group B, n=85, procedures from January 2011 to May 2013).
  
  
  RESULTS
  Five deaths (3.3%) occurred within 30 days, with a decrease in 30-day mortality between the 2 groups (group A, n=4, 6.2%; group B, n=1, 1.2%) that became significant at 1 year (log-rank, P=.002). Severe bleeding from the apex (group A, 4.6%; group B 4.4%) and deployment of >1 valve (group A, 7.6%; group B, 10.5%) was similar in both groups. Valve embolization was less frequent in group B (group A, 4.6%; group B, 2.4%). Postoperative complications in groups A and B included stroke (3.1% vs 0%), renal failure (9.3% vs 4.7%), and permanent pacemaker implantation (6.1% vs 5.9%). No myocardial infarctions occurred in either group. Two patients received simultaneous aortic and mitral valve implantation; 1 patient undergoing TA-TAVR also underwent distal arch and descending aorta repair; all had favorable outcomes. With a further 25 TA-TAVR since May 2013, the overall mortality is 2.9% (5/175).
  
  
  CONCLUSIONS
  Although working with the fragile apical tissues in high-risk elderly patients remains a challenge, we have demonstrated a reduction in mortality and complications with increasing experience in TA-TAVR. We have successfully demonstrated novel combined procedures and uses for the transapical approach and alternate access sites, which should continue to be explored.
authors.affiliation: Case Western Reserve University School of Medicine, Cleveland, Ohio.
authors.forename: Jason
authors.initials: J
authors.lastname: Aguirre
authors.affiliation: Marshall University Joan C. Edwards School of Medicine, Huntington, WVa.
authors.forename: Robin
authors.initials: R
authors.lastname: Waskowski
authors.affiliation: Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Kanhaiya
authors.initials: K
authors.lastname: Poddar
authors.affiliation: Section of Intervention, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Samir
authors.initials: S
authors.lastname: Kapadia
authors.affiliation: Section of Intervention, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Amar
authors.initials: A
authors.lastname: Krishnaswamy
authors.affiliation: Department of Cardiothoracic Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Rebecca
authors.initials: R
authors.lastname: McCullough
authors.affiliation: Department of Cardiothoracic Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Mick
authors.affiliation: Department of Cardiothoracic Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Jose L
authors.initials: JL
authors.lastname: Navia
authors.affiliation: Department of Cardiothoracic Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Eric E
authors.initials: EE
authors.lastname: Roselli
authors.affiliation: Section of Intervention, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Murat E
authors.initials: ME
authors.lastname: Tuzcu
authors.affiliation: Department of Cardiothoracic Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Joseph F
authors.initials: JF
authors.lastname: Sabik
authors.affiliation: Department of Cardiothoracic Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Bruce W
authors.initials: BW
authors.lastname: Lytle
authors.affiliation: Department of Cardiothoracic Surgery, Heart and Vascular Institute, 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; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001026:Coronary Artery Bypass; D017548:Echocardiography, Transesophageal; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D018579:Patient Selection; D011183:Postoperative Complications / Q000401:mortality; D012189:Retrospective Studies; D018570:Risk Assessment; D015996:Survival Rate; D065467:Transcatheter Aortic Valve Replacement / Q000379:methods* / Q000401:mortality; D016896:Treatment Outcome