title: Access path angle in transapical aortic valve replacement: risk factor for paravalvular leakage.
abstract: BACKGROUND
  The aim of this study was to analyze the angle between the left ventricular (LV) long axis and the LV outflow tract (αLV-LVOT) on cardiac computed tomography and to describe its effect on the occurrence of paravalvular leakage (PL), fluoroscopy time, and postoperative creatine kinase-MB levels in transapical transcatheter aortic valve replacement (TA-TAVR).
  
  
  METHODS
  High-risk patients with severe aortic stenosis scheduled for TA-TAVR using an Edwards SAPIEN (Edwards Lifesciences, Irvine, CA) prosthesis were retrospectively included. The αLV-LVOT was measured during systole and diastole as far as retrospectively gated data sets were available. The αLV-LVOT was correlated with the occurrence of PL, total fluoroscopy time, and postoperative creatine kinase-MB levels. Interobserver variability was assessed in all cases.
  
  
  RESULTS
  The study included 81 patients (57 women [70.4%], 24 men [29.6%]) with an average age of 81.9±5.8 years. The mean αLV-LVOTs were 61.8±9.9 degrees during systole and 61.1±10.0 degrees during diastole. There was a minimal, nonsignificant change in the αLV-LVOT between systole and diastole of 0.2±4.1 degrees (p=0.7). PL was found in 39 patients: grade 0 in 42 (51.9%), grade I in 30 (37.0%), and grade II in 9 (11.1%). Patients with a clinically significant PL (grade≥II) showed a significantly greater mean αLV-LVOT than patients with grade I or without PL (mean difference, 13.8±3.2 degrees; p<0.001). No significant correlation was found between the αLV-LVOT and total fluoroscopy time (r=-0.17, p=0.16) and postoperative creatine kinase-MB levels (r=-0.1, p=0.44).
  
  
  CONCLUSIONS
  During TA-TAVR, greater αLV-LVOTs were associated with significantly higher grades of PL. Thus, the αLV-LVOT might influence the selection of the transapical implantation path and could have a significant effect on designs for future stents or novel delivery devices.
authors.affiliation: Department of Interventional and Diagnostic Radiology, University of Leipzig-Heart Center, Leipzig, Germany. Electronic address: borek.foldyna@herzzentrum-leipzig.de.
authors.forename: Borek
authors.initials: B
authors.lastname: Foldyna
authors.affiliation: Clinic of Cardiac Surgery, University of Leipzig-Heart Center, Leipzig, Germany.
authors.forename: Martin
authors.initials: M
authors.lastname: Hänsig
authors.affiliation: Department of Interventional and Diagnostic Radiology, University of Leipzig-Heart Center, Leipzig, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Lücke
authors.affiliation: Clinic of Cardiac Surgery, University of Leipzig-Heart Center, Leipzig, Germany.
authors.forename: David
authors.initials: D
authors.lastname: Holzhey
authors.affiliation: Department of Interventional and Diagnostic Radiology, University of Leipzig-Heart Center, Leipzig, Germany.
authors.forename: Claudia
authors.initials: C
authors.lastname: Andres
authors.affiliation: Department of Interventional and Diagnostic Radiology, University of Leipzig-Heart Center, Leipzig, Germany.
authors.forename: Matthias
authors.initials: M
authors.lastname: Grothoff
authors.affiliation: Department of Cardiology, University of Leipzig-Heart Center, Leipzig, Germany.
authors.forename: Axel
authors.initials: A
authors.lastname: Linke
authors.affiliation: Clinic of Cardiac Surgery, University of Leipzig-Heart Center, Leipzig, Germany.
authors.forename: Friedrich Wilhelm
authors.initials: FW
authors.lastname: Mohr
authors.affiliation: Department of Interventional and Diagnostic Radiology, University of Leipzig-Heart Center, Leipzig, Germany.
authors.forename: Matthias
authors.initials: M
authors.lastname: Gutberlet
authors.affiliation: Department of Interventional and Diagnostic Radiology, University of Leipzig-Heart Center, Leipzig, Germany.
authors.forename: Lukas
authors.initials: L
authors.lastname: Lehmkuhl
mesh_terms: D000369:Aged, 80 and over; D001021:Aortic Valve / Q000000981:diagnostic imaging / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000601:surgery*; D001027:Aortography; D018618:Echocardiography, Doppler, Color; D017548:Echocardiography, Transesophageal; D004562:Electrocardiography; D005260:Female; D005471:Fluoroscopy; D005500:Follow-Up Studies; D005858:Germany / Q000453:epidemiology; D006350:Heart Valve Prosthesis; D006801:Humans; D015994:Incidence; D008297:Male; D061330:Multidetector Computed Tomography; D011183:Postoperative Complications / Q000175:diagnosis / Q000453:epidemiology*; D011474:Prosthesis Design; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D065467:Transcatheter Aortic Valve Replacement / Q000379:methods*