Apical Access Management in Transapical Transcatheter Mitral Valve Replacement

Background The role of the surgical technique and anatomy in transapical mitral valve replacement are scarcely investigated. Methods Computed tomography scans, surgical reports and planning slides of 127 patients undergoing transapical mitral valve replacement with the Tendyne valve system (Abbott Vascular) at 15 centers, participating in a European observational study, were retrospectively analyzed and compared between patients with (cohort A) and without (cohort B) apical access complications (AACs). Results A total of 8 (6.3%) AACs were recorded, of which 7 of 8 were observed in the first 10 patients of the respective center. Patients with AACs showed a trend to a thinner myocardium at the target access compared with those with regular access (median 4.4 vs 6.1 mm, P = .086). Technical difficulties along with AACs were reflected by a significant longer procedural time (median 180 vs 123 min, P = .011), higher rates of circulation support (50% vs 0%, P < .001), valve retrieval (38% vs 3%, P = .005), and bailout full sternotomy (13% vs 0%, P = .063). AACs were related with an intraprocedural mortality and in-hospital mortality rate of 25% (vs 0%, P = .010) and 50% (vs 7%, P = .003), respectively. In total, 8 of 12 in-hospital deaths were attributed to AACs and/or sepsis. AACs significantly increased the risk for 30-day (adjusted odds ratio, 19.5; 95% CI, 2.19–178.3; P = .008) and in-hospital mortality (adjusted hazard ratio, 9.00; 95% CI, 1.95–41.42; P = .005). Conclusions Access complications in transapical mitral valve replacement are relatively rare but associated with poor short-term outcome. Focus on the apical myocardium within the screening process and specific surgical training might avoid AACs and improve outcome.