Use of a Ventricular Septal Defect Occluder for Apical Closure in Transapical Aortic Valve Replacement

摘要

During transapical transcatheter aortic valve replacement (TA-TAVR), the apical closure remains a challenge for the surgeon, having the risk for ventricular tear and massive bleeding. Apical closure devices are already under clinical evaluation, but only a few can lead to a full percutaneous TA-TAVR. We describe the successful use of a 9-mm myocardial occluder (ventricular septal defect occluder) that was used to seal the apex after a standard TA-TAVR (using the Sapien XT 23-mm transcatheter valve and the Ascendra + delivery system). The placement of the nonmodified myocardial occluder was performed through the Ascendra + delivery system, with a very small amount of blood loss and an acceptable sealing of the apical tear. This approach is feasible and represents a further step toward true-percutaneous transapical heart valve procedures. Modified apical occluders are under evaluation in animal models. Transapical transcatheter aortic valve replacement (TA-TAVR) is performed in high-risk patients with peripheral vascular disease. The apical access is traditionally performed through a left minithoracotomy (7-10 cm) at the fifth intercostal space and requires a double reinforced purse-string suture or multiple reinforced U-fashion stitches. Unfortunately, despite new delivery systems with low profiles, the apical access remains a challenge, having the risk for ventricular tear and life-threatening bleeding.1 Moreover, the traditional surgical apical access limits the development of lesser-invasive transapical valve procedures such as very small intercostal incisions (3-4 cm), the video-assisted thoracoscopic TA-TAVR, or the true percutaneous TA-TAVR.