Transseptal and Transapical

Antegrade Access for TEVAR

Sabine Wipper, MD, Christina Lohrenz, MD Tilo Kölbel, MD, PhD

University Heart Center University Hospital Eppendorf

Hamburg, Germany

Disclosures

Ü  Research-grants, travelling, speaking-fees, IP with Cook.

Ü  Research-grant, travelling, speaking-fees with Cordis

Background

Ü  Treatment of choice for pathologies in the ascending aorta and the aortic arch is open surgical repair

Ü  Severe comorbidities exclude some patients from surgical treatment

Ø  Hypothesis:

Less invasive endovascular treatment options to avoid median stertotomy, aortic cross-clamping and cardiopulmonary bypass are necessary

Why Transcardiac Access?

Ü  Access across aortic valve technically easier

Ü  Lower damage risk of narrow or kinked aorto-iliac and femoral access vessels

Ü  Access-profile nearly unlimited

Ü  Short approach to target

Ü  Better device control (straight orientation)

Ü  Easy access to branches

Why Transcardiac Access?

Ü  Easier stabilization against systolic jet

Ü  Drainage of pericardial effusion

Ü  Availability (cardiac-units)

Ü  …

How to use it?

Ü  Through & through wire access

Ü  Introduction of main stent-graft

Ü  Branch vessel access

Ü  …

Transcardiac Access Routes

Ü  Transseptal access

Ü  Transapical access

Transapical Access

Ü  Well established Access

Ü  Standard access for TAVI

Ü  Few casereports for TEVAR

Ü  Open mini-thoracotomy, incision of pericardium

Ü  ….

Transapical Access

Transapical Through & Through

Transapical TEVAR

Szeto et al 2010, Ann Thorac Surg 89: 616-8 MacDonald et al 2009, JVS 49: 759-62

Ü  67 year-old male

Ü  Acute type A dissection

Ü  Pericardial tamponade

Ü  Severe comorbidities

Transapical TEVAR in Acute Type A Dissection

Transapical TEVAR in Acute Type A Dissection

Transapical TEVAR in Acute Type A Dissection

Transapical TEVAR in Acute Type A Dissection

Transapical TEVAR in Acute Type A Dissection

12h postop.

Transapical TEVAR in Acute Type A Dissection

6m postop.

Branch Vessel Access

Percutaneous Transapical TEVAR

Transapical Branchvessel-access

Perc. Transapical Closure

Transseptal Access

Pigtail katheter

EPU katheter

Transseptal sheath

Transseptal Access

Transseptal Access

Transseptal Access

Transseptal Puncture - History

Ü  Joseph1997: Carotid artery stenting

Ü Dorros 2000: Stent-graft stabilization

Ü Cribier 2002: Aortic valve replacement

Joseph et al; Cathet Cardiovasc Diagn. 1997

Ü 65 year-old female

Ü 6,5cm TAA

Ü Multiple Kinks

Ü Morbidly obese

Transseptal Throughwire Access

Transseptal Throughwire Access

Transseptal Throughwire Access

Transseptal TEVAR

Transseptal Branchvessel-access

Critical Issues

Ü  Transapical access: Ü  Surgical exposure required Ü Pericardium to be crossed Ü ……….

Ü  Transseptal access: Ü  Strain to anterior mitral leaflet Ü  Transient mitral reflux Ü ……….

Summary

Transcardiac access:

Ü  Standard access for Aortic valve implantation

Ü  Different access-routes through the heart

Ü  Short distance, straight route, profile nearly unrestricted

Ü  Relevance of transcardiac access yet to be defined

Thank you very much for your attention

Perc. Transapical Closure

Ü  32 patients, pred. paravalvular leak closure

Ü  5-12F sheaths

Ü  Amplatzer-occludes

Jelnin et al. 2011JACC: Cardiovasc Interv 4:868-74

Perc. Transapical Closure

Jelnin et al. 2011JACC: Cardiovasc Interv 4:868-74

Transapical Through & Through

Ramponi et al 2011, JEVT 18: 350-4

Ü  Single case report

Ü  Mini-thorakotomy

Transapical TEVAR

Ü  Few casereports

Ü  Well established Access

Ü  Cardiac axis