Transapical Transcatheter Aortic Valve Implantation for a Patient with Severe Iliac Artery Stenosis: Our Surgical Ingenuity for Frail Patients

Abstract

We started transcatheter aortic valve implantation (TAVI) in 2018, and while accumulating 391 cases, we have developed a transapical approach that can be performed safely with good reproducibility, so we will introduce our surgical ingenuity in this case report.

The case was an 85-year-old woman diagnosed with symptomatic severe aortic valve stenosis. Considering her age, surgical risk, and frailty, TAVI was indicated. Although the aortic annulus was small, her aortic root anatomy was suitable for TAVI. Because of occlusion and severe stenosis at the bilateral iliac arteries, a transapical approach was chosen. After 5th intercostal left thoracotomy, two horizontal mattress sutures of 3-0 prolene SH needles with felt were placed near the apex of the left ventricular anterior wall, in which the stiff wire was punctured and placed. After inserting the 18 Fr sheath, the SAPIEN3 23 mm is implanted uneventfully without peri-valvular regurgitation which was confirmed by transesophageal echocardiogram. The sheath was removed and the puncture site was closed with already placed 3-0 prolene sutures under ventricular tachycardia induced by temporary pacing in order to control blood pressure and wall tension at the apex. The postoperative course was uneventful and she was discharged to home a week after surgery.