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Letters to the Editor |
Universität Leipzig, Herzzentum, Klinik für Herzchirurgie, Strümpellstr. 39, 04289 Leipzig, Germany
Received 23 October 2008; accepted 24 October 2008.
* Corresponding author. Tel.: +49 341 865 1424; fax: +49 341 865 1452. (Email: walt{at}medizin.uni-leipzig.de).
Key Words: Aortic valve • Minimally invasive • Transcatheter techniques • Transapical • Aortic valve implantation
Apostolakis et al. [1] brought up some comments regarding transapical aortic valve implantation (TA-AVI) and we would like to thank them for their contribution.
In their first paragraph they compare the results of our initial 50 patients receiving TA-AVI to patients receiving transfemoral or conventional aortic valve replacement from other studies [2]. Comparison of the overall outcome in this high-risk patient population to other studies may lead to wrong conclusions. The study by Grossi et al. [3] that was used for comparison included younger patients and an overall much lower risk profile. We have observed that TA-AVI is feasible in very high-risk elderly patients and that it is associated with a very low stroke rate. Prospectively randomized clinical trials will have to be performed. At no point did we state, however, that TA-AVI is now the gold standard for treating patients with aortic stenosis [2].
We have consistently indicated the clear need for a team approach and for a ‘safety net’, that is the ability to use CPB or conversion to sternotomy at any time if required, for TA-AVI procedures. The relatively high rate of CPB quoted in our article [1] is a reflection of the fact that we initially placed all patients on femoral CPB because of the novelty of the procedure at that time. The progression to ‘CPB standby’ has been one of the most important developments over the past three years.
Regarding the authors’ question on hemodynamic status, all patients had sufficient cardiac output postoperatively. Continuous measurement of cardiac output, however, was not routinely performed in the postoperative care of patients receiving TA-AVI. Brief episodes of rapid ventricular pacing are well tolerated with no obvious increase in myocardial enzymes. In addition, we were unable to detect any specific negative impact of rapid ventricular pacing upon short- and long-term outcomes.
Paravalvular leakage was of a minor degree in most patients, with no evidence of hemolysis in any patient. In addition, no patient was readmitted with congestive heart failure because of severe paravalvular leakage. Fortunately we have not yet seen any patient suffering postoperative endocarditis.
The aspects that the authors summarize under point ‘D’ are somewhat unclear. We thought to avoid sternotomy, CPB, aortic cross-clamping and possible retrograde valve implantation.
In summary TA-AVI is an antegrade and relatively straight-forward procedure. It allows for optimal direct manipulation and thus very precise positioning of a transcatheter-delivered aortic valve prosthesis. TA-AVI is a true minimally invasive procedure and can routinely be performed off-pump by an experienced team. Following the initial feasibility studies, results are further improving: during the past two years mortality has decreased, stroke rate remains low and conversion rate to either CPB or sternotomy is low. We therefore feel that TA-AVI is an attractive therapeutic option for elderly high-risk patients with aortic stenosis.
References
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