Percutaneous transapical access: current status

Percutaneous transapical access provides a direct route to many cardiac structures difficult to reach with conventional interventional approaches. With recent developments of new technologies in structural heart disease, there has been an increasing interest in the use of transapical access for cardiac interventions. Meticulous planning, careful access and closure techniques are essential. Development of novel imaging technologies and dedicated closure devices are warranted to allow a greater number of operators to successfully adopt percutaneous transapical access and further reduce complication rates. This article is an overview of the current status and utility of percutaneous transapical access with focus on multimodality imaging, technique and potential complications of this approach

Available Transcatheter Aortic Valve Replacement Technology

Transcatheter aortic valve replacement (TAVR) is an alternative and now recommended therapy for patients who meet indications for surgical valve replacement and are high or prohibitive surgical risk. Available TAVR technologies are rapidly emerging to treat this complex patient population. This review discusses the specific valve designs of the transcatheter heart valves currently used, newer generation modifications to overcome limitations of earlier valve designs, and novel imaging modalities, such as computed tomographic angiography-fluoroscopy and echocardiography-fluoroscopy fusion imaging, available for pre-procedural planning and intra-procedural guidance

Percutaneous closure of left ventricular pseudoaneurysm

Background-Left ventricular pseudoaneurysm is a rare but serious complication from myocardial infarction and cardiac surgery. Although standard treatment is surgical intervention, percutaneous closure of left ventricular pseudoaneurysm has become an option for high-risk surgical candidates. Experience with percutaneous treatment is limited to a few single case reports. This is the first series of percutaneous treatment of the left ventricular pseudoaneurysms. Methods and Results-This is a retrospective analysis of 9 procedures of percutaneous repair of left ventricular pseudoaneurysm in 7 consecutive patients (ages 51 to 83 years, 6 men) completed in our Structural Heart Disease center from June 2008 to December 2010. All patients were considered as a high risk for surgery because of multiple comorbidities. Multiple imaging modalities were used before, during, and after the procedures to improve success and efficacy. The left ventricular pseudoaneurysms of all 7 patients were successfully repaired. Fluoroscopy time on average was 36.5±24.0 minutes (range, 12.4 to 75.7 minutes). All patients were followed up for a period ranging from 3 to 32 months after the procedure. Each patient improved by at least 1 New York Heart Association functional class, and 4 patients improved by 2 classes. Conclusions-Transcatheter closure of the left ventricular pseudoaneurysm is a feasible alternative for high-risk surgical candidates. The use of multiple imaging modalities is required for a detail planning and execution of the procedure. © 2011 American Heart Association, Inc

Novel Percutaneous Apical Exclusion of a Left Ventricular Pseudoaneurysm After Complicated Transapical Transcatheter Aortic Valve Replacement

A 78-year-old woman with a history of coronary artery bypass grafting underwent transapical transcatheter aortic valve replacement with a Sapien XT (Edwards, Irvine, California) prosthesis that was complicated by an apical left ventricular pseudoaneurysm (LVPA). Unsuccessful attempts at closure included percutaneous, retrograde transaortic placement of a 12-mm Amplatzer Ventricular Septal Defect occluder (St. Jude Medical, Minneapolis, Minnesota) and surgical CorMatrix (CorMatrix, Roswell, Georgia) patch repair on cardiopulmonary bypass, both with residual expanding and/or recurrent LVPA. A novel transcatheter approach was performed to exclude the left ventricular apex and flow into the LVPA. Using computed tomography–fluoroscopy fusion imaging (HeartNavigator, Philips, Best, the Netherlands), percutaneous transapical access was performed adjacent to the true apical site of the LVPA. The 26-mm Amplatzer septal and 35-mm Amplatzer cribriform occluders were positioned and deployed with the distal disks overlapping, excluding the apical cavity, and the proximal disks positioned on the epicardial surface. Residual flow was noted through the polyester fabric of the devices, and an additional percutaneous transapical access through the LVPA exit site was performed with placement of a 4-F sheath. Three 0.052-inch 10 × 15-mm coils (Cook Medical, Bloomington, Indiana) soaked in thrombin were placed within the excluded apical segment. Echocardiography revealed no further flow into the LVPA, with increased echogenicity of the sac suggesting thrombosis. Computed tomography performed prior to discharge confirmed total occlusion of the LVPA with complete apical exclusion (Figure 1)

Successful first-in-man percutaneous transapical-transseptal Melody mitral valve-in-ring implantation after complicated closure of a para-annular ring leak

AIMS: Transcatheter techniques can theoretically be applied to the treatment of para-annular ring (PAR) leaks. Little is known about their potential application and resultant complications in such cases. We describe the first-in-man percutaneous transapical-transseptal Melody valve-in-ring (ViR) implantation after a complication from percutaneous PAR leak closure. METHODS AND RESULTS: A 49-year-old woman, at high operative risk, presented with congestive heart failure secondary to severe para-ring/extravalvular regurgitation two months after bypass surgery and mitral ring annuloplasty. Successful percutaneous closure of the leak was performed using an AMPLATZER Vascular Plug IV. One month later, she developed haemolysis with severe PAR regurgitation, through and around the device. After device retrieval and placement of an AMPLATZER Muscular VSD occluder, the patient developed severe intravalvular regurgitation. Completely percutaneous, transseptal delivery of a Melody ViR was performed over a transapical-transseptal, arteriovenous rail. Echocardiography revealed trivial residual regurgitation through the implanted valve with mild transvalvular gradients. CONCLUSIONS: Percutaneous closure of mitral PAR leaks after ring annuloplasty in the high-risk patient is feasible (proof-of-concept), particularly when the leak is para-ring/extravalvular. Potential complications include severe intravalvular mitral regurgitation caused by disruption of the mitral apparatus and/or ring deformation during device deployment, which can be successfully treated via percutaneous transapical-transseptal ViR implantation

Optimal Imaging for Guiding TAVR: Transesophageal or Transthoracic Echocardiography, or Just Fluoroscopy?

THE FOLLOWING iFORUM DEBATE FEATURES 3 VIEWPOINTS related to the most practical and effective imaging strategy for guiding transcatheter aortic valve replacement (TAVR). Kronzon, et al. provide evidence that enhanced analysis of abrtic valve anatomy and improved appreciation of complications mandate the use of transesophageal echocardiography as front-Line imaging modality for ALL patients undergoing TAVR. On the other hand, Saric and colleagues compare and contrast the approach of performing TAVR under transthoracic guidance. Lastly, Kasel and co-workers provide preliminary evidence that TAVR could be performed under fluoroscopic guidance without the need for additional imaging technique. Although the use of Less-intensive sedation or anesthesia might reduce the procedural time, we need more randomized data to establish the most cost-effective approach in guiding TAVR

Percutaneous complete repair of failed mitral valve prosthesis: simultaneous closure of mitral paravalvular leaks and transcatheter mitral valve implantation - single-centre experience

Aims: Structural deterioration and paravalvular leak (PVL) are complications associated with surgically implanted prosthetic valves, historically requiring reoperation. We present our experience of complete transcatheter repair of a degenerated mitral bioprosthesis. Methods and results: From March 2012 to October 2012, we reviewed consecutive, high-risk surgical patients (n=5) who underwent transcatheter repair of a failed mitral bioprosthesis with severe paravalvular regurgitation (PVR). Manufacturer valve sizes ranged from 27 to 33 mm, regurgitation (n=1), stenosis (n=1), or both (n=3). Percutaneous transapical and transseptal access were achieved with PVL closure performed transapically. An arteriovenous rail was created for transseptal delivery of a Melody valve. All patients had successful PVL closure with no residual PVR. Valve-in-valve (ViV) implantation was successful in four patients. Overall, mean transvalvular mitral gradient was 11.2 mmHg pre-procedure which improved to 5 mmHg post-procedure. Improvement of NYHA Class \u3e/=2 was achieved in all patients (19+/-3 months). One patient had controlled Melody valve embolisation which required emergent surgical replacement. Inner valve diameter was 26 mm, too large for Melody valve implantation. Conclusions: Complete transcatheter repair of a degenerated mitral bioprosthesis with PVR can be performed in the high-risk patient. Accurate measurement is necessary prior to intervention, with concern for embolisation among the larger valve sizes (\u3e31 mm)