Cioni Micaela, Taramasso Maurizio, Giacomini Andrea, Montorfano Matteo, Latib Azeem, Colombo Antonio, Alfieri Ottavio, Maisano Francesco
Cardiac Surgery Department, San Raffaele University Hospital, Milan, Italy.
Innovations (Phila). 2011 Nov;6(6):361-5. doi: 10.1097/IMI.0b013e318248e9ed.
Transcatheter aortic valve implantation (TAVI) is increasingly accepted as an alternative procedure in patients with severe, symptomatic aortic stenosis and high risk for surgical aortic valve replacement. Transfemoral (TF) approach is the first option when feasible, but in case of peripheral vascular disease this approach is precluded. In our institution, for this kind of patients we considered transaxillary (TAx) approach as second choice and transapical (TAp) or transaortic (TAa) as last routes. This study describes short- and mid-term morbidity and mortality for TAx approach.
From November 2007 to March 2011, 284 patients underwent TAVI at our site; 229 treated by TF approach, 22 TAp, 2 TAa, and 31 TAx. Four patients were treated with an Edwards Sapien valve (Edwards Lifesciences, Inc., Irvine, CA USA) with TAx approach and 27 with CoreValve Revalving System (Medtronic Inc., Minneapolis, MN USA). TAx TAVI was performed in cath-laboratory with local anesthesia and mild sedation by a multispeciality valve team. We analyzed major adverse cardiac and cerebrovascular events, major adverse valve-related events, vascular complications, and 30 days and 6 months mortality.
The procedural success rate (successful implantation of the device without intraprocedural mortality or need to conversion to open heart surgery) was 96.8% (30/31). Major adverse valve-related events were 12.9% (4/31). 30-day mortality was 6.4% (2/31) and actuarial survival at 6 months was 82.95% ± 7.96%. In one patient, procedure was converted to a TF CoreValve in emergency for hemodynamic instability after valvuloplasty due to severe difficulty to introduce the Edwards valve in the subclavian artery.
TAx approach is a feasible and technically simple procedure with encouraging results considering morbidity and mortality at short- and mid-term follow-up. TAx is a valid solution in patients with contraindications to TF approach and it is an alternative approach potentially less invasive than TAp or TAa.
经导管主动脉瓣植入术（TAVI）越来越多地被视为重度有症状主动脉瓣狭窄且外科主动脉瓣置换术风险高的患者的替代手术。可行时，经股动脉（TF）途径是首选，但如果存在外周血管疾病，则无法采用该途径。在我们机构，对于这类患者，我们将经腋动脉（TAx）途径视为第二选择，经心尖（TAp）或经主动脉（TAa）途径视为最后选择。本研究描述了TAx途径的短期和中期发病率及死亡率。
2007年11月至2011年3月，284例患者在我院接受了TAVI；229例采用TF途径治疗，22例采用TAp途径，2例采用TAa途径，31例采用TAx途径。4例患者采用TAx途径植入爱德华兹Sapien瓣膜（美国加利福尼亚州尔湾市爱德华兹生命科学公司），27例采用美敦力公司（美国明尼苏达州明尼阿波利斯）的CoreValve Revalving System瓣膜。TAx TAVI在导管实验室由多专业瓣膜团队在局部麻醉和轻度镇静下进行。我们分析了主要不良心脑血管事件、主要不良瓣膜相关事件、血管并发症以及30天和6个月死亡率。
手术成功率（成功植入装置且术中无死亡或无需转为心脏直视手术）为96.8%（30/31）。主要不良瓣膜相关事件发生率为12.9%（4/31）。30天死亡率为6.4%（2/31），6个月精算生存率为82.95%±7.96%。1例患者在瓣膜成形术后因难以将爱德华兹瓣膜引入锁骨下动脉导致血流动力学不稳定，紧急情况下转为TF CoreValve手术。
TAx途径是一种可行且技术上简单的手术，考虑到短期和中期随访的发病率和死亡率，结果令人鼓舞。TAx对于TF途径禁忌的患者是一种有效的解决方案，并且是一种潜在的比TAp或TAa侵入性更小的替代途径。
