Apical-access-related complications associated with trans-catheter aortic valve implantation

Objective: The left-ventricular trans-apical access has become well established for trans-catheter aortic valve implantation, especially for patients in whom a retrograde trans-arterial implantation is contraindicated. We report on the short-and long-term implications of the apical-access-site-specific complications. Methods: Between June 2007 and August 2010, 143 patients were scheduled for trans-apical aortic valve implantation (mean age 80 +/- 6 years, n = 116 females, mean logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) 21 +/- 13%). The patients are followed up at 30 days, 6 months, and then annually. Results: Severe apical bleeding complications occurred in 10 patients (7%). In three of these patients, the procedure was terminated, and no valve was implanted. In the remaining, the bleeding was controlled with cardiopulmonary bypass support (n = 3), via median sternotomy (n = 1), or both (n = 1) +/- later re-exploration. Two additional patients required postprocedural re-exploration for apical bleeding. An apical pseudo-aneurysm developed in two patients (2%), one of whom was treated by surgical revision. Survival was significantly impaired when either apical bleeding, aneurysm, or re-exploration occurred (75% +/- 0.082 survival at 30 days and 59% +/- 0.122 at 1 year vs 94% +/- 0.023 and 80% +/- 0.043 in patients without apical complications, p = 0.012). Twelve patients (8%) experienced secondary wound healing. An apical hypo-or akinesia was detected in 18/54 (33%) patients at 6 months' echocardiographic investigation, and in 11/30 (37%) 1 year after the procedure. Conclusions: The trans-apical access for trans-catheter aortic valve implantation might be challenging in elderly patients with fragile tissue. Severe bleeding complications or aneurysm formation significantly impairs survival. The clinical impact of subsequent apical hypo-or akinesia has to be further followed up. (C) 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.