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Multidisciplinary Approach to Transcatheter Aortic Valve Replacement (TAVR) access site planning: A Single Center Experience with Edwards SAPIEN ™ Trans catheter Heart Valve (THV)
Nicholas Sikalas, MD, Rajesh K. Malik, MD, Jason C. Kovacic, MD, Marvin V. Weaver, MD, Rami O. Tadros, MD, Ageliki G. Vouyouka, MD, Samin K. Sharma, MD, David H. Adams, MD, Michael L. Marin, MD, Peter L. Faries, MD, Sharif H. Ellozy, MD.
The Mount Sinai Hospital, NY, NY, USA.
Objective:
At our institution a multidisciplinary team approach involving Cardiology, Cardiothoracic and Vascular surgery is used to plan appropriate access for Trans-catheter aortic valve delivery.
Methods:
93 extremely high risk patients underwent placement of the Edwards SAPIEN ™ Trans catheter Heart Valve (THV) for severe aortic stenosis over an 18 month period. CT Angiograms with 3-D reconstructions were reviewed for access vessel calcification, caliber, and tortuosity.
Results:
There were a total of 93 patients (67 females & 26 males) of which 46 underwent trans-femoral access (TF, 32 open, 14 percutaneous), 24 required iliac exposure (TI), 14 underwent trans apical (TA) approach and 9 direct-aortic (DA). TF was the default access if possible, followed by TI and then either TA or DA depending on surgical anatomy. Utilizing standardized access complication criteria (VARC-2) TF access offered the lowest complication rate. There were 0 major and 6(18.7%) minor vascular complications. TI exposure had major and minor complication rates of 7(29.1%) and 5(20.8%) respectively. Of the major complications 5 patients experienced hematomas requiring multiple transfusion, 2 required reoperation for suspected continued bleeding. The other 2 major complications include intra-op bleeding and an iliac artery dissection with thrombosis; all which were repaired successfully during the initial procedure. TA approach had 2(14.2%) major & 1(7.1%) minor complication. DA approach also resulted in 2(22.2%) major and 1(11.1%) minor vascular complication. Both TA and DA had 1 mortality each from ventricular perforation.
Conclusion:
Appropriate access planning and selection is a major determinant in TAVR outcomes. Our success in our TAVR program is largely due to our Multidisciplinary approach to vascular access. TF is best when technically and anatomically feasible. When TF is limited by anatomic constraints, other approaches are acceptable.
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