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Thomas Walther
Todd Dewey
Gerhard Wimmer-Greinecker
Mirko Doss
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Friedrich W. Mohr
Michael Mack
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Eur J Cardiothorac Surg 2006;29:703-708
© 2006 Elsevier Science NL

Transapical approach for sutureless stent-fixed aortic valve implantation: experimental results

Thomas Walther a , * , Todd Dewey b , Gerhard Wimmer-Greinecker c , Mirko Doss c , Rainer Hambrecht d , Gerhard Schuler d , Friedrich W. Mohr a , Michael Mack b

a Universität Leipzig, Herzzentrum, Klinik für Herzchirurgie, Strümpellstrasse 39, 04289 Leipzig, Germany
b Cardiopulmonary Research Science and Technology Institute, Department of Cardiac Surgery, Dallas, TX, USA
c Klinik für Thorax-, Herz- und Thorakale Gefässchirurgie, JW-Goethe Universität Frankfurt, Germany
d Universität Leipzig, Herzzentrum, Klinik für Kardiologie, Leipzig, Germany

Received 26 October 2005; received in revised form 16 January 2006; accepted 30 January 2006.

* Corresponding author. Tel.: +49 341 865 1424; fax: +49 341 865 1452. (Email: walt{at}medizin.uni-leipzig.de).

Objective: Percutaneous aortic valve implantation has been performed in patients with severe aortic stenosis judged as nonsurgical candidates. We evaluated a facilitated transapical antegrade approach for potential use in surgical high-risk patients. Methods: A pericardial xenograft fixed within a 23-mm stent (Cribier–Edwards aortic prosthesis, Edwards Inc., Irvine, CA, USA) was implanted using a transapical approach in fifteen 35–45 kg pigs. A limited or a full sternotomy was used to transapically introduce a crimped valve through a 24-F sheath. Deployments were performed on the beating heart either with ventricular unloading using femoro-femoral cardiopulmonary bypass (CPB) or rapid ventricular pacing (RVP), all under fluoroscopic and echocardiographic visualization. Results: All valves were successfully deployed at the target site with acceptable visualization of the noncalcified annulus. Valve migration occurred in six procedures (three distal and three retrograde) secondary to inadequate reduction of ventricular output, unfavorable annular anatomy, excessive crimping of the valve, and dislodgement by the delivery balloon. Exact positioning of the valve into the target area was confirmed by autopsy at the end of the procedures. Paravalvular leak was noted in five implants. Conclusions: The transapical approach provides a safe, accurate, and effective route for facilitated antegrade delivery of a stent-fixed valve. Advanced stent design will lead to better stability of the implant and may minimize the risk of paravalvular leakage in future. Identifying the appropriate population for human feasibility trials remains a challenge.

Key Words: Aortic valve replacement • Stent-fixed aortic valve • Transapical approach • Beating heart cardiac surgery




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