title: Right anterior mini-thoracotomy direct aortic self-expanding trans-catheter aortic valve implantation: A single center experience.
abstract: OBJECTIVE
  Transcatheter aortic valve implantation (TAVI) has been designed to treat elderly patients with severe aortic stenosis at high risk for surgery. These patients are also often affected by severe iliac-femoral arteriopathy, rendering the trans-femoral approach unusable. We report our experience with the direct-aortic approach to treat these patients.
  
  
  METHODS
  From May 2008 to November 2013 two hundred and thirty-two patients (131 female, 56%) with severe symptomatic aortic stenosis and no reasonable surgical option due to excessive risk were evaluated for TAVI at our department. Of these patients, 202 were deemed eligible for TAVI. Of this group, 50 underwent CoreValve implantation by the direct aortic approach through a right anterior mini-thoracotmy (28 female, 56%), mean age 81.2±6.9. A combined team of cardiologists, cardiac surgeons with expertise in hybrid procedures, and anesthetists performed all the procedures.
  
  
  RESULTS
  Twenty-eight (56%) patients were female and 11 (22%) were redo at TAVI. We used a 23-mm CoreValve Evolute in 3 patients (6%), and the most used valve size was the 29mm in 46% of patients. Mean hemodynamic trans-aortic gradient was less than 5mmHg. The paravalvular regurgitation was ≤ grade 1 in 46 patients as assessed by peri-procedural transesophageal echocardiography (TEE). Seven patients (7/43, 16%) required a permanent pacemaker implantation; 30-day mortality was 6% (3 patients). Seven patients (14.8%) died during follow-up. Actuarial survival at 2years is 84.7±5.3%.
  
  
  CONCLUSIONS
  Transcatheter aortic valve implantation with the direct aortic approach is safe and feasible, offering a new attractive option to treat selected high-risk patients with severe aortic stenosis and peripheral vasculopathy, including those requiring a re-do procedure.
authors.affiliation: "A. De Gasperis" Cardiology & Cardiac Surgery Department, Niguarda Ca' Granda Hospital, Italy. Electronic address: giuseppe.bruschi@fastwebnet.it.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Bruschi
authors.affiliation: "A. De Gasperis" Cardiology & Cardiac Surgery Department, Niguarda Ca' Granda Hospital, Italy.
authors.forename: Federico
authors.initials: F
authors.lastname: De Marco
authors.affiliation: "A. De Gasperis" Cardiology & Cardiac Surgery Department, Niguarda Ca' Granda Hospital, Italy.
authors.forename: Luca
authors.initials: L
authors.lastname: Botta
authors.affiliation: "A. De Gasperis" Cardiology & Cardiac Surgery Department, Niguarda Ca' Granda Hospital, Italy.
authors.forename: Alberto
authors.initials: A
authors.lastname: Barosi
authors.affiliation: "A. De Gasperis" Cardiology & Cardiac Surgery Department, Niguarda Ca' Granda Hospital, Italy.
authors.forename: Paola
authors.initials: P
authors.lastname: Colombo
authors.affiliation: "A. De Gasperis" Cardiology & Cardiac Surgery Department, Niguarda Ca' Granda Hospital, Italy.
authors.forename: Silvia
authors.initials: S
authors.lastname: Mauri
authors.affiliation: "A. De Gasperis" Cardiology & Cardiac Surgery Department, Niguarda Ca' Granda Hospital, Italy.
authors.forename: Aldo
authors.initials: A
authors.lastname: Cannata
authors.affiliation: "A. De Gasperis" Cardiology & Cardiac Surgery Department, Niguarda Ca' Granda Hospital, Italy.
authors.forename: Nuccia
authors.initials: N
authors.lastname: Morici
authors.affiliation: "A. De Gasperis" Cardiology & Cardiac Surgery Department, Niguarda Ca' Granda Hospital, Italy.
authors.forename: Tiziano
authors.initials: T
authors.lastname: Colombo
authors.affiliation: "A. De Gasperis" Cardiology & Cardiac Surgery Department, Niguarda Ca' Granda Hospital, Italy.
authors.forename: Pasquale
authors.initials: P
authors.lastname: Fratto
authors.affiliation: Cardiothoracic Anesthesia and Intensive-care, Niguarda Ca' Granda Hospital, Italy.
authors.forename: Sandra
authors.initials: S
authors.lastname: Nonini
authors.affiliation: "A. De Gasperis" Cardiology & Cardiac Surgery Department, Niguarda Ca' Granda Hospital, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Soriano
authors.affiliation: Cardiothoracic Anesthesia and Intensive-care, Niguarda Ca' Granda Hospital, Italy.
authors.forename: Michele
authors.initials: M
authors.lastname: Mondino
authors.affiliation: "A. De Gasperis" Cardiology & Cardiac Surgery Department, Niguarda Ca' Granda Hospital, Italy.
authors.forename: Cristina
authors.initials: C
authors.lastname: Giannattasio
authors.affiliation: "A. De Gasperis" Cardiology & Cardiac Surgery Department, Niguarda Ca' Granda Hospital, Italy.
authors.forename: Silvio
authors.initials: S
authors.lastname: Klugmann
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000473:pathology / Q000601:surgery; D001024:Aortic Valve Stenosis / Q000175:diagnosis* / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D013908:Thoracotomy / Q000379:methods*; D065467:Transcatheter Aortic Valve Replacement / Q000295:instrumentation* / Q000379:methods*
keywords: Aortic stenosis; Aortic valve; Minimally invasive surgery; Thoracotomy; Transcatheter valve replacement