Transapical minimally invasive aortic valve implantation

Objective: To evaluate the feasibility of minimally invasive transapical placement (TAP) of an aortic valve xenograft using an oversizing technique for high risk patients with aortic stenosis.

Methods: TAP was performed via a small anterolateral minithoracotomy with or without femoro-femoral extracorporeal circulation (ECC) on the beating heart. A pericardial xenograft fixed within a stainless steel, balloon expandable stent (Cribier-Edwards Ascendra™, Edwards Lifesciences, Irvine, CA, USA) was used. 30 consecutive patients (82±5.1 years, 21 (70%) female) were operated since 02/2006 at one center using fluoroscopic and echocardiographic visualization. Average EuroSCORE predicted risk for mortality was 27±12%.

Results: TAP valve positioning was performed successfully in 29 patients, one required early conversion. Implantation (8×23mm and 22×26mm valves) was performed on the beating heart during brief periods of rapid ventricular pacing. ECC was applied in 13 patients. Neither coronary artery obstruction nor migration of the prosthesis was observed, all had good hemodynamic function. Echocardiography revealed minor paravalvular leakage in 11 patients (mild in 7 and trace in 4). Three patients (10%) died, one on POD 3 with preoperative global myocardial failure and two on POD 18 and 86 due to abdominal complications.

Conclusions: Transapical minimally invasive aortic valve implantation is feasible using an off pump technique. Initial results are excellent, especially when considering the overall high risk profile of these patients. Longer term outcome will have to be studied.