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Background: We present the case of a patient who underwent successful transapical aortic valve implantation in a severe quadricuspid aortic valve (QAV) with severe regurgitation and multiorgan failure. Case Summary: A 57‐year‐old man experienced intermittent palpitation and shortness of breath for 6 months. The condition deteriorated in the past month and caused multiorgan failure. The echocardiography and computed tomography angiography revealed severe aortic regurgitation due to congenital QAV. The aortic valve replacement was successfully performed in this high‐risk patient using a J‐Valve system. Postoperation and follow‐up were uneventful. Conclusion: The J‐Valve system effectively treated QAV regurgitation with good clinical outcomes in this case. [ABSTRACT FROM AUTHOR]

Abstract Background Quadricuspid aortic valve (QAV) is a rare congenital heart defect usually accompanied with different hemodynamic abnormalities. Due to the rarity of QAV, treatment and prognosis of QAV patients with aortic regurgitation still remain challenging. We here present the first case of a patient with severe QAV regurgitation who underwent successful treatment and performed favorable prognosis with transapical aortic valve implantation (TAVI) using J-Valve system. Case presentation A 62-year-old man experienced intermittent palpitation, shortness of breath and chest pain. Echocardiography revealed congenital QAV with massive aortic regurgitation and mild aortic stenosis, left ventricular enlargement. Aortic valve replacement was successfully performed with TAVI using J-Valve system. The postoperation and follow-up was uneventful. Conclusion TAVI using J-Valve system has emerged as a new high success rate method for treatment of patients with simple non-calcified aortic valve insufficiency.

Background: Quadricuspid aortic valve (QAV) is a rare congenital heart defect usually accompanied with different hemodynamic abnormalities. Due to the rarity of QAV, treatment and prognosis of QAV patients with aortic regurgitation still remain challenging. We here present the first case of a patient with severe QAV regurgitation who underwent successful treatment and performed favorable prognosis with transapical aortic valve implantation (TAVI) using J-Valve system.Case Presentation: A 62-year-old man experienced intermittent palpitation, shortness of breath and chest pain. Echocardiography revealed congenital QAV with massive aortic regurgitation and mild aortic stenosis, left ventricular enlargement. Aortic valve replacement was successfully performed with TAVI using J-Valve system. The postoperation and follow-up was uneventful.Conclusion: TAVI using J-Valve system has emerged as a new high success rate method for treatment of patients with simple non-calcified aortic valve insufficiency. [ABSTRACT FROM AUTHOR]

Abstract Background Transcatheter aortic valve implantation is indicated in high-risk patients with aortic stenosis. We compared the clinical outcome of 180 consecutive patients who underwent transapical (TA) and transfemoral (TF) procedures in a single centre. Methods Ninety consecutive TA (TA-group) and 90 consecutive TF (TF-group) were performed from 2009 to 2014. Clinical variables were prospectively collected and retrospectively analysed for hospital outcomes and to identify risk factors for hospital mortality, vascular complications and stroke. Results Mean age was 80 ± 8.5 and 83 ± 8.4 years, in the TA and TF-group, respectively. TA-group presented higher prevalence of comorbidities: more vascular disease (79% vs 22%, p

Background Silent brain infarcts (SBI) are increasingly being recognized as an important complication of cardiac procedures as well as a potential surrogate marker for studies on brain injury. The extent of subclinical brain injury is poorly defined. Methods and Results We conducted a systematic review and meta‐analysis utilizing studies of SBIs and focal neurologic deficits following cardiac procedures. Our final analysis included 42 studies with 49 separate intervention groups for a total of 2632 patients. The prevalence of SBIs following transcatheter aortic valve implantation was 0.71 (95% CI 0.64‐0.77); following aortic valve replacement 0.44 (95% CI 0.31‐0.57); in a mixed cardiothoracic surgery group 0.39 (95% CI 0.28‐0.49); coronary artery bypass graft 0.25 (95% CI 0.15‐0.35); percutaneous coronary intervention 0.14 (95% CI 0.10‐0.19); and off‐pump coronary artery bypass 0.14 (0.00‐0.58). The risk ratio of focal neurologic deficits to SBI in aortic valve replacement was 0.22 (95% CI 0.15‐0.32); in off‐pump coronary artery bypass 0.21 (95% CI 0.02‐2.04); with mixed cardiothoracic surgery 0.15 (95% CI 0.07‐0.33); coronary artery bypass graft 0.10 (95% CI 0.05‐0.18); transcatheter aortic valve implantation 0.10 (95% CI 0.07‐0.14); and percutaneous coronary intervention 0.06 (95% CI 0.03‐0.14). The mean number of SBIs per patient was significantly higher in the transcatheter aortic valve implantation group (4.58 ± 2.09) compared with both the aortic valve replacement group (2.16 ± 1.62, P=0.03) and the percutaneous coronary intervention group (1.88 ± 1.02, P=0.03). Conclusions SBIs are a very common complication following cardiac procedures, particularly those involving the aortic valve. The high frequency of SBIs compared with strokes highlights the importance of recording this surrogate measure in cardiac interventional studies. We suggest that further work is required to standardize reporting in order to facilitate the use of SBIs as a routine outcome measure.

Background: Transcatheter aortic valve implantation is indicated in high-risk patients with aortic stenosis. We compared the clinical outcome of 180 consecutive patients who underwent transapical (TA) and transfemoral (TF) procedures in a single centre.Methods: Ninety consecutive TA (TA-group) and 90 consecutive TF (TF-group) were performed from 2009 to 2014. Clinical variables were prospectively collected and retrospectively analysed for hospital outcomes and to identify risk factors for hospital mortality, vascular complications and stroke.Results: Mean age was 80 ± 8.5 and 83 ± 8.4 years, in the TA and TF-group, respectively. TA-group presented higher prevalence of comorbidities: more vascular disease (79% vs 22%, p < 0.001), chronic pulmonary disease (32% vs 10%, p < 0.001), previous vascular surgery (14% vs 4%, p = 0.039), coronary disease (60% vs 40%, p = 0.007), and previous cardiac surgery (28% vs 17%, p = 0.073). Logistic Euroscore was 36 ± 15% in the TA-group and 25 ± 14% in the TF-group (p < 0.001), but hospital mortality was similar (TA:9%, TF:10%, p = 0.799). Access-related vascular complications occurred more often in transfemoral patients (TA:3%, TF:11%, p = 0.081) while major bleeding (TA:3%, TF:4%, p = 1) and stroke (TA:2%, TF:3%, p = 1) were equally distributed. Postoperative renal failure and dialysis were associated with impaired neurological outcome (p = 0.035 and p = 0.020, respectively). Mild to severe paravalvular leak was more prevalent in transfemoral patients (TA:5%, TF:25%, p < 0.001).Conclusions: In our experience, the TA and TF-group presented different risk profiles but mortality rate and adverse neurological outcome had a similar incidence. The transfemoral approach carried more vascular complications and paravalvular leaks but last-generation devices will improve this outcome. [ABSTRACT FROM AUTHOR]

Objectives This analysis reports on the initial German multicenter experience with the JenaValve (JenaValve Technology GmbH, Munich, Germany) transcatheter heart valve for the treatment of pure aortic regurgitation. Background Experience with transcatheter aortic valve implantation (TAVI) for severe aortic regurgitation is limited due to the risk of insufficient anchoring of the valve stent within the noncalcified aortic annulus. Methods Transapical TAVI with a JenaValve for the treatment of severe aortic regurgitation was performed in 31 patients (age 73.8 ± 9.1 years) in 9 German centers. All patients were considered high risk for surgery (logistic EuroSCORE [European System for Cardiac Operative Risk Evaluation] 23.6 ± 14.5%) according to a local heart team consensus. Procedural results and clinical outcomes up to 6 months were analyzed. Results Implantation was successful in 30 of 31 cases (aortic annulus diameter 24.7 ± 1.5 mm); transcatheter heart valve dislodgement necessitated valve-in-valve implantation in 1 patient. Post-procedural aortic regurgitation was none/trace in 28 of 31 and mild in 3 of 31 patients. During follow-up, 2 patients underwent valvular reinterventions (surgical aortic valve replacement for endocarditis, valve-in-valve implantation for increasing paravalvular regurgitation). All-cause mortality was 12.9% and 19.3% at 30 days and 6 months, respectively. In the remaining patients, a significant improvement in New York Heart Association class was observed and persisted up to 6 months after TAVI. Conclusions Aortic regurgitation remains a challenging pathology for TAVI. After initial demonstration of feasibility, this multicenter study revealed the JenaValve transcatheter heart valve as a reasonable option in this subset of patients. However, a significant early noncardiac mortality related to the high-risk population emphasizes the need for careful patient selection. [ABSTRACT FROM AUTHOR]

OBJECTIVES The aim of this study was to evaluate the initial and short-term results of a new apical access and closure device to facilitate and standardize the transapical (TA) approach to transcatheter aortic valve implantation (TAVI). METHODS The apical access, stabilization and closure (ASC™) device consists of three components: an introducer system, a left ventricular low-profile titanium coil and a closure cap. The ASC™ introducer system is anchored and rotated into the myocardium almost like a corkscrew, using the titanium coil. Following the TA-AVI procedure, the closure cap is introduced and delivered through the system into the titanium coil for final sealing. RESULTS A total of 11 high-risk elderly patients (EuroSCORE I: 27.8 ± 16.7; EuroSCORE II: 6.6 ± 5.0 and The Society of Thoracic Surgeons (STS) score: 5.9 ± 2.7%) were evaluated for TA-AVI by our interdisciplinary Heart Team and subsequently included in the trial after informed consent was obtained. One patient was excluded due to the presence of deep epicardial fat tissue. In all other cases, the titanium coil provided sufficient sealing throughout the procedure without the presence of perisheath bleeding. After delivery of the closure cap, no relevant bleeding was observed in any patient. Pericardial drainages were removed early in all patients. One patient suffered from non-device-related pericardial effusion requiring surgical decompression on postoperative day 6. Two patients suffered from delayed minor strokes, most likely due to arrhythmia. All patients received aspirin, clopidogrel and low molecular heparin after the procedure. Discharge echocardiography revealed no changes in left ventricular function when compared with baseline and no new onset wall motion abnormalities. All 10 patients were alive at 30 days. CONCLUSIONS TA access and closure are both feasible and safe using the APICA ASC™ device. The system facilitates and standardizes TA access and closure by providing a sufficient and secure sealing during and after the TA-AVI procedure. [ABSTRACT FROM PUBLISHER]

Objective: Transapical aortic valve implantation (TAVI) may lead to obstruction of coronary arteries during deployment. To prevent this, it is essential to determine the distance of the coronary ostium to the aortic annulus prior to valve placement. Multidetector computed tomography (MDCT) commonly is used to determine these measurements, but even marginal exposure to contrast agents can result in acute kidney injury in this high-risk group of multi-morbid patients. The aim of the study was to determine the feasibility of real-time 3D transesophageal echocardiography (RT 3D TEE) as the first-choice technique for noninvasive evaluation of the coronary ostium during TAVI. Design: Retrospective study. Setting: University hospital. Interventions: Fifty patients underwent MDCT the evening before surgery. RT 3D TEE was performed intraoperatively before valve deployment. The dataset from both of these examinations was digitally stored and evaluated. MDCT was performed in nonanesthetized patients; however, in the RT 3D TEE group, general anesthesia was established. Measurements and Main Results: The distances from the right coronary artery and the left coronary artery ostium were measured retrospectively. Bland-Altman Plots and linear regression analysis showed excellent correlation between the 2 methodologies; intraobserver and interobserver variance were calculated using analysis of variance. Krippendorff's α indicated excellent agreement between the 2 observers (0.96 and 0.98) as well as between RT 3D TEE and MDCT (0.97 and 0.98). Conclusions: The observations showed that RT 3D TEE reliably can measure the coronary ostium distance from the aortic annulus. It is feasible and an alternative method for evaluating these measurements and thereby preventing contrast exposure during MDCT, which may jeopardize the safety of patients with pre-existing renal disease. [Copyright &y& Elsevier]

Objectives: This study sought to report on the feasibility and early results of transcatheter aortic valve implantation employing a second-generation device in a series of patients with pure aortic regurgitation. Background: Efficacy and safety of transcatheter aortic valve implantation in patients with calcific aortic stenosis and high surgical risk has been demonstrated. However, experience with implantation for severe noncalcified aortic regurgitation has been limited due to increased risk for valve dislocation or annular rupture. Methods: Five patients (mean age: 66.6 ± 7 years) underwent transapical implantation of a JenaValve (JenaValve Technology GmbH, Munich, Germany) transcatheter heart valve for moderate to severe, noncalcified aortic regurgitation. All patients were considered high risk for surgical aortic valve replacement after evaluation by an interdisciplinary heart team (logistic EuroSCORE [European System for Cardiac Operative Risk Evaluation] range 3.1% to 38.9%). Procedural and acute clinical outcomes were analyzed. Results: Implantation was successful in all cases without relevant remaining aortic regurgitation or signs of stenosis in any of the patients. No major device- or procedure-related adverse events occurred and all 5 patients were alive with improved exercise tolerance at 3-month follow-up. Conclusions: Noncalcified aortic regurgitation continues to be a challenging pathology for transcatheter aortic valve implantation due to the risk for insufficient anchoring of the valve stent within the aortic annulus. This report provides first evidence that the JenaValve prosthesis may be a reasonable option in these specific patients due to its unique stent design, clipping the native aortic valve leaflets, and offering promising early results. [Copyright &y& Elsevier]

OBJECTIVE Patients undergoing transapical aortic valve implantation (TA-AVI) are usually over 80 years old and have a high prevalence of chronic kidney disease. However, transcatheter valve therapies require the use of contrast injections with the risk of nephrotoxicity. The aim of this study was to evaluate post-operative kidney function and survival in patients with pre-existing renal impairment with regard to the amount of contrast media used during TA-AVI. METHODS From January 2008 to March 2011, 50 patients (52% females, mean age 80.7 ± 5.3 years) with a serum creatinine level of >1.3 mg/dl were investigated. Patients receiving a dose of <100 ml of a contrast agent (low-dose group, n = 24) were separated from those who received >100 ml of a contrast agent (high-dose group, n = 26). An acute contrast-induced nephropathy (CIN) was defined as a serum creatinine increase of 0.5 mg/dl or by >25% of a baseline value within 48 h from contrast medium administration. Patients in both groups had similar characteristics in terms of age, sex, body mass index and comorbidities. RESULTS The median pre-contrast creatinine was 1.67 (1.37–1.83) mg/dl in the low-dose group and 1.51 (1.26–1.98) mg/dl in the high-dose group (P = 0.76). The post-contrast creatinine at 48 h was 1.53 (1.33–2.05) and 2.29 (1.67–2.86) mg/dl in the groups receiving low- and high-dose contrast agents, respectively (P = 0.007). CIN occurred in 41.7% (n = 10) of patients in the low-dose contrast group and in 69.2% (n = 18) in the high-dose contrast group (P = 0.046). Haemodialysis is necessary for 16.7% of the low-dose group and 38.5% of the high-dose group (P = 0.12). Trends towards longer intensive care unit and hospital stay were seen in patients with an extensive use of contrast media [4.3 (2.5–6.5) vs. 5 (3–7.8) days and 12 (9–14.3) vs. 13 (9–18) days, P = 0.091 vs. P = 0.546, respectively]. Regarding death, 3-month and 3-year mortality were significantly higher in the high-dose group (8.3 vs. 30.8%, P = 0.036 and 25 vs. 61.5%, P = 0.004, respectively). CONCLUSIONS Our results indicate a possible association between higher CIN and mortality rate and the extensive use of contrast media during TA-AVI among high-risk patients with pre-existing renal impairment. [ABSTRACT FROM AUTHOR]

Standard surgical aortic valve replacement with a biological prosthesis remains the treatment of choice for low- and mid-risk elderly patients (traditionally >65 years of age) suffering from severe symptomatic aortic valve stenosis or insufficiency, and for young patients with formal contraindications to long-lasting anticoagulation. Unfortunately, despite the fact that several technical improvements have noticeably improved the resistance of pericardial and bovine bioprostheses to leaflet calcifications and ruptures, the risk of early valve failure with rapid degeneration still exists, especially for patients under haemodialysis and for patients <60 years of age at the time of surgery. Until now, redo open heart surgery under cardiopulmonary bypass and on cardioplegic arrest was the only available therapeutic option in case of bioprosthesis degeneration, but it carried a higher surgical risk when elderly patients with severe concomitant comorbidities were concerned. Since a few years, the advent of new transcatheter aortic valve procedures has opened new horizons in cardiac surgery and, in particular, the possibility of implanting stented valves within the degenerated stented bioprosthesis, the so-called ‘valve-in-valve’ (VinV) concept, has become a clinical practice in experienced cardiac centres. The VinV procedure represents a minimally invasive approach dedicated to high-risk redo patients, and published preliminary reports have shown a success rate of 100% with absence of significant valvular leaks, acceptable transvalvular gradients and low complication rate. However, this procedure is not riskless and the most important concerns are about the size mismatch and the right positioning within the degenerated bioprosthesis. In this article, we review the limited available literature about VinV procedures, underline important technical details for the positioning and provide guidelines to prevent valve–prosthesis mismatch comparing the three sizes of the only commercially available transapical device, the Edwards Sapien™, with the inner diameter of three of the most commonly used stented bioprostheses. [ABSTRACT FROM AUTHOR]

Purpose: Transapical aortic valve implantation (TA-AVI) is a new minimally invasive surgical treatment of aortic stenosis for high-risk patients. The placement of aortic valve prosthesis (AVP) is performed under 2D X-ray fluoroscopic guidance. Difficult clinical complications can arise if the implanted valve is misplaced. Therefore, we present a method to track the AVP in 2D X-ray fluoroscopic images in order to improve the accuracy of the TA-AVI. Methods: The proposed tracking method includes the template matching approach to estimate the position of AVP and a shape model of the prosthesis to extract the corner points of the AVP in each image of sequence. To start the AVP tracking procedure, an initialization step is performed by manually defining the corner points of the prosthesis in the first image of sequence to provide the required algorithm parameters such as the AVP model parameters. Results: We evaluated the AVP tracking method on six 2D intra-operative fluoroscopic image sequences. The results of automatic AVP localization agree well with manually defined AVP positions. The maximum localization errors of tracked prosthesis are less than 1 mm and within the clinical accepted range. Conclusions: For assisting the TA-AVI, a method for tracking the AVP in 2D X-ray fluoroscopic image sequences has been developed. Our AVP tracking method is a first step toward automatic optimal placement of the AVP during the TA-AVI. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Transcatheter aortic valve implantation is a new method for the treatment of very-high-risk patients with aortic valve stenosis. Particularly in patients who have had previous cardiac surgery, the operative risk can be reduced. Nevertheless, this new procedure has some potential risks in these patients, due to the increased danger of endocarditis and in view of potential graft damage after previous bypass grafting or prosthesis damage after previous valve replacement, caused by wire manipulation or valve liberation. Methods: Between April 2008 and January 2010, 198 consecutive patients underwent transapical aortic valve implantation. Group A consisted of 158 patients without previous heart surgery and group B had 40 patients with previous heart operation (23 coronary artery bypass grafting, three aortic valve replacements, two mitral valve repairs, one replacement, and 11 combined operations). Although patients in group B (75±11) were significantly younger than the ones in group A (80±8) (p =0.003), the preoperative risk score was significantly higher in group B (group A – the European System for Cardiac Operative Risk Evaluation (EuroSCORE): 37±18%; the Society of Thoracic Surgeons (STS) mortality score: 21±16; group B – EuroSCORE: 53±21%; STS mortality score: 29±18) (p <0.001, p =0.006). Results: The technical success rate was 99.5% (157/158) in group A and 100% (40/40) in group B. One patient in group A developed an annulus rupture. The postoperative echocardiographic examinations showed low transvalvular gradient due to the special design of the valve, without differences between the two groups. The 30-day mortality was 6.9% in group A and 5.0% in group B, and the 1-year survival was 77% and 74% in group A and group B, respectively (nonsignificant). Conclusions: Transcatheter valve implantation can be performed successfully after previous heart surgery. Particular care should be taken to achieve optimal valve position and not to damage grafts or prosthetic valves during manipulation with guide wires or valve positioning. [Copyright &y& Elsevier]

Aims The Medtronic Engager™ aortic valve bioprosthesis is a self-expanding valve with support arms facilitating anatomically correct positioning and axial fixation. Valve leaflets, made of bovine pericardium, are mounted on a Nitinol frame. Here, we report the first in man study with this new implant (Trial Identifier NCT00677638). Methods and results Thirty patients (mean age 83.4 ± 3.8 years; 83% female) with tricuspid aortic valve stenosis were included in the study. Mean logistic EuroSCORE was 23.4 ± 11.9. Mean aortic annulus diameter was 21.8 ± 1.4 mm. For this study, the Engager was available in only one size (23 mm), to fit aortic annuli of 19–23 mm. Standard transapical valve implantation was performed using predilation of the aortic valve and rapid ventricular pacing during ballon valvuloplasty and most valve deployments. Accurate valve placement was achieved in 29/30 cases (97%). Post-implant peak-to-peak gradient was 13.3 ± 9.3 mmHg. In 80% of the patients, no more than grade I paravalvular leakage was observed, in 13% grades I–II and in 3% grade II. Three patients (10%) required permanent pacemaker implantation for higher-degree or complete atrioventricular block. Four dissections (13%) occurred during positioning of the valve and were treated surgically in three cases. Thirty-day and in-hospital mortality were 20% and 23%, respectively, and 6-month survival was 56.7%. No structural failure occurred for up to 1 year. Conclusion This series established the feasibility of implanting a novel self-expanding transapical aortic valve prosthesis predictably into an anatomically correct position. Observed complications led to complete redesign of the delivery system for upcoming clinical studies with the goal of establishing safety and performance. [ABSTRACT FROM PUBLISHER]

Objectives: This study assessed the rate of periprocedural embolic ischemic brain injury during transapical aortic valve replacement in 25 consecutive patients. Background: Transcatheter aortic valve implantation is rapidly being established as a new therapeutic approach for aortic valve stenosis. Although initial clinical results are promising, it is unknown whether mobilization and embolization of calcified particles may lead to cerebral ischemia. Methods: Twenty-five consecutive patients (10 men, 15 women, mean age: 81 ± 5 years, mean log EuroSCORE [European System for Cardiac Operative Risk Evaluation]: 32 ± 10%) scheduled for transapical aortic valve implantation were included. All patients received a baseline cerebral magnetic resonance imaging scan. The scan was repeated approximately 6 days after valve implantation. The magnetic resonance imaging studies included axial diffusion–weighted, T2-weighted, fluid attenuated inversion recovery–weighted, and T2 gradient echo sequences. Standardized assessment of the neurologic status was performed before aortic valve replacement and post-operatively. Results: Transapical aortic valve implantation was successfully performed in all patients. In 17 patients (68%), new cerebral lesions could be detected, whereas 8 patients showed no new cerebral insults. The pattern of distribution and morphology were typical of embolic origin. Despite the high incidence of morphologically detectable lesions, only 5 patients showed clinical neurologic alterations. Out of these patients, only 1 suffered from a permanent stroke. Conclusions: New embolic ischemic cerebral insults are detected in 68% of patients after transapical valve implantation. Clinical symptoms are rare and usually transitory. Larger trials will need to establish the clinical significance of asymptomatic ischemic lesions as well as the rate of ischemic events in patients undergoing transfemoral valve replacement. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To evaluate the feasibility of minimally invasive transapical beating heart aortic valve implantation (TAP-AVI) for high-risk patients with aortic stenosis. Methods: TAP-AVI was performed via a small anterolateral minithoracotomy in 50 patients from February 2006 to March 2007. A balloon expandable transcatheter xenograft (Edwards SAPIEN™ THV, Edwards Lifesciences, Irvine, CA, USA) was used. Mean age was 82.4±5 years and 39 (78%) were female. Implantation was performed in a hybrid operative theatre using fluoroscopic and echocardiographic visualization. Average EuroSCORE predicted risk for mortality was 27.6±12%. Seven (14%) patients were re-operations with patent bypass grafts. Results: TAP-AVI (13 patients 23mm and 37 patients 26mm) was successfully performed on the beating heart under temporary rapid ventricular pacing in 47 (94%) patients, and implantation was performed completely off-pump in 34 (68%) patients. Three patients required early conversion; two of them were successfully discharged. There was no prosthesis migration or embolization observed. Echocardiography revealed good hemodynamic function in all and minor incompetence in 23 patients, mostly paravalvular, without any signs of hemolysis. Mortality was due to the overall health condition and non-valve related in all patients. Actuarial survival at 1 month, 6 months and 1 year was 92±3.8%, 73.9±6.2% and 71.4±6.5%, respectively. Conclusions: Transapical minimally invasive aortic valve implantation is feasible using an off-pump technique. Good results have been achieved in the initial 50 patients, especially when considering the overall high-risk profile of these patients. [Copyright &y& Elsevier]

Abstract: Objective: To evaluate the feasibility of minimally invasive transapical beating heart aortic valve implantation (TAP-AVI) for high-risk patients with aortic stenosis. Methods: TAP-AVI was performed via a small anterolateral minithoracotomy with or without femoral extracorporeal circulation (ECC) on the beating heart. A pericardial xenograft fixed within a stainless steel, balloon expandable stent (Cribier-Edwards, Edwards Lifesciences, Irvine, CA, USA) was used. Thirty consecutive patients (82±5.1 years, 21 (70%) female) were operated from 02/06 until 09/06 at one center using fluoroscopic and echocardiographic visualization. Average EuroSCORE predicted risk for mortality was 27±12%. Results: Valve positioning was successful in 29 patients and one required early conversion to full sternotomy. Implantation (8mm×23mm and 22mm×26mm valves) was performed on the beating heart during brief periods of rapid ventricular pacing. ECC was applied in 13 patients. Neither coronary artery obstruction nor migration of the prosthesis was observed and all valves displayed good hemodynamic function. Echocardiography revealed minor paravalvular leakage in 14 patients (trace in three, mild in nine and moderate in two). Three patients (10%) died, one on postoperative day (POD) three secondary to preoperative global myocardial failure and two on POD 18 and 86 due to abdominal complications. Conclusions: Minimally invasive beating heart TAP-AVI is feasible. Initial results are encouraging in view of the high-risk profile of the patients. Long-term studies as well as randomized protocols are required. [Copyright &y& Elsevier]

The article presents a case study of a 92-year-old male with severe symptomatic aortic stenosis, diabetes, and renal failure. The patient successfully undergone transapical coronary intervention while undergoing transapical catheter-based aortic valve implantation and was discharged with good condition from the hospital 0 days after the operation. It discusses coronary artery intervention through transapical approach.

Objectives: To evaluate a new transapical system which utilizes a novel designed positioning element and a two-step positioning mechanism for easy and accurate implantation of transcatheter valves., Background: Transcatheter aortic valve implantation is an important treatment option for non-surgical patients with severe aortic stenosis. However, accurate placement of the transcatheter valve remains challenging., Methods: Self-expandable aortic valve prosthesis with a flexibly connected, annulus-like positioning element was implanted through a transapical approach in 12 pigs. The positioning element was separated and can be released independent of the valve prosthesis. During valve implantation, firstly, the positioning element was unsheathed and fixed into the aortic sinus. Then, the prosthetic valve was guided to an anatomically oriented position and deployed. Six animals were followed up to 180 days., Results: With the help of the positioning element, all 12 valves were successfully deployed at the anticipated site. The valve release procedure took an average of 7.3 ± 2.5 min. The mean transvalvular pressure gradient was 2.8 ± 1.1 mm Hg at valve deployment. Of the six chronic animals, the mean transvalvular pressure gradient was 3.0 ± 1.0 mm Hg on day 7, and 2.9 ± 1.6 mm Hg on day 180 (P = 0.91). No migration, embolization, or coronary obstruction was observed during surgery and at necropsy. Pathological examination showed anatomically correct positioning of the prosthetic valve without signs of thrombosis or calcification., Conclusions: In this study, we confirmed the feasibility of the J-Valve transapical system for transapical implantation through a two-step process. Satisfactory hemodynamic and pathological performance during a follow-up of 180 days was demonstrated. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

A response from the authors of the article about transcatheter aortic valve and aortic homograft reintervention that was published in the previous issue is presented.

Transapical transcatheter aortic valve implantation (TA-TAVI) is the recognized first choice surgical TAVI access. Expansion of this well-established treatment modality with subsequent broader patient inclusion has accelerated development of second-generation TA-TAVI devices. The Swiss ACURATE TA Symetis valve allows for excellent anatomical positioning, resulting in a very low incidence of paravalvular leaks. The self-expanding stent features an hourglass shape to wedge the native aortic valve annulus. A specially designed delivery system facilitates controlled release aided by tactile operator feedback. The ACURATE TA valve made of three native porcine non-coronary leaflets has received CE approval in September 2011. Since then, this valve is the third most frequently implanted TAVI device with over 1200 implants in Europe and South America. Results from the Symetis ACURATE TA™ Valve Implantation ('SAVI') Registry showed a procedural success rate of 98.0% and a survival rate of 93.2% at 30 days. This presentation provides technical considerations and detailed procedural aspects of device implantation., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Transcatheter aortic valve implantation (TAVI) is a new method for the treatment of very high-risk patients with aortic valve stenosis. The radiation dose to which the patient and each member of the heart team are exposed during this new fluoroscopically guided intervention is unknown., Methods: Between April 2008 and August 2013, 1177 consecutive patients underwent transapical TAVI (TA-TAVI). In 22 consecutive patients undergoing TA-TAVI, the radiation doses to the cardiothoracic surgeon, cardiologist, anaesthesiologist (performing echocardiography examination), surgical assistant and nurse were measured. The radiation dose measurements were performed during TAVI using thermoluminescence and film dosimeters positioned on seven parts of the body: (i) chest above the lead apron, (ii) pelvic area below the apron, (iii) chest below the apron, (iv) thyroid gland above the apron, (v) near eyes, (vi) hands (using rings) and (vii) the feet. The results were compared with the values given in the international literature on recommended radiation dose limits for workers., Results: The mean radiation time was 6.1 min and the mean dose-area product for the patients was 8.661 µGy · m(2). Analysis of the dosimeters and the calculation of the effective dose showed a per intervention dose of 0.03 mSv for the surgeon, 0.05 mSv for the assistant, 0.02 mSv for the cardiologist and the anaesthesiologist and 0.001 mSv for the nurse. The maximum ionizing radiation per intervention was 0.5 mSv at the right hand of the surgeon (holding the introducer sheet) and 0.7 mSv at the left hand of the surgical assistant. Additionally, the analysis of the body dose shows a maximum dose to the lower leg of the surgeon (0.3 mSv) and the genital area of the assistant (0.06 mSv)., Conclusions: During a TA-TAVI procedure, the patients receive a higher X-ray dose than during coronary angiography with intervention. After 100 TAVI procedures, the members of the heart team sustain a comparable dose of ionizing radiation to the annual dose received by a busy interventional cardiologist. Therefore, maximal safety and optimal X-ray protection for patients and the members of the team are crucial and should be redefined.

Background: There are no direct comparisons between transapical aortic valve implantation (TA-AVI) and transfemoral aortic valve implantation (TF-AVI). Therefore, the aim of this study was to compare the short-term and midterm outcomes of TA-AVI versus TF-AVI., Methods: Data from four European centers were pooled and analyzed. To minimize differences between TA-AVI and TF-AVI multivariable analysis was used. Study endpoints were defined according to the Valve Academic Research Consortium-I criteria at 30 days and 1 year. Primary endpoints of this study were 30-day all-cause mortality and mortality during follow-up., Results: A total of 882 patients underwent TAVI, of whom 793 (89.9%) underwent TF-AVI and 89 (10.1%) underwent TA-AVI. Patients undergoing TA-AVI had a higher estimated risk of mortality as defined by the logistic European System for Cardiac Operative Risk Evaluation score (median 27.0, interquartile range [IQR]: 20.2 to 33.8 versus median 20.0, IQR: 12.3 to 27.7; p < 0.001) and The Society of Thoracic Surgeons Score (median 10.2, IQR: 5.3 to 9.9 versus median 6.7, IQR: 3.5 to 9.9; p < 0.001) and had more comorbidities. At 30 days, there was an increased risk of all-cause mortality in the TA-AVI group (odds ratio [OR] 3.12, 95% confidence interval [CI]: 1.43 to 6.82; p = 0.004). TF-AVI was associated with a higher frequency of major (OR 0.33, 95% CI: 0.12 to 0.90; p = 0.031) and minor vascular complications (OR 0.17, 95% CI: 0.04 to 0.71; p = 0.0015). In-hospital stay was significantly longer among patients undergoing TA-AVI (OR 2.29, 95% CI: 1.28 to 4.09; p = 0.05). During a median follow-up of 365 days (IQR: 174 to 557), TA-AVI was associated with an increased risk of all-cause mortality (hazard ratio 1.88, 95% CI: 1.23 to 2.87; p = 0.004)., Conclusions: In institutions performing a low volume of TA-AVI, the technique is associated with an increased risk of all-cause mortality and longer hospital stay but less vascular complications in comparison with TF-AVI. The interaction between experience and type of treatment on outcome requires further investigation before advocating one treatment over the other., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Surgical aortic valve replacement (AVR) still remains the treatment of choice in symptomatic significant aortic stenosis (AS). Due to technical problems, extensive calcification of the ascending aorta ("porcelain aorta") is an additional risk factor for surgery and transapical aortic valve implantation (TAAVI) is likely to be the only rescue procedure for this group of patients. We describe the case of an 81-year-old woman with severe AS and "porcelain aorta", in whom the only available life-saving intervention was TAAVI.