Right Axillary Edwards SAPIEN 3 TAVR Implanted via Apical Certitude Delivery System

TAVR is now the gold standard in the treatment of aortic stenosis in high risk patients. The transfemoral approach has been shown to be a reliable access method for TAVR. However, in patients with severe PAD, this access may be very challenging. In this setting, the axillary approach may be indicated (1). The Edwards SAPIEN valve has already been implanted in this manner with good results (2). The transfemoral delivery system requires additional maneuvers in the ascending aorta in order to insert the balloon at the level of the valve. The new apical Certitude delivery system seems to be very helpful in these patients when compared to the old Ascendra system. It has a reduced 18 Fr diameter, and the balloon is already integrated into the valve. The authors find that this may be very useful, as it facilitates implantation.

In the following video, a right axillary Edwards SAPIEN 3 TAVR is implanted through the new apical Certitude delivery system. The patient was an 80-year-old man suffering from chronic renal failure, severe PAD (with previous right carotid TEA), and left subclavian ICD. He presented with NYHA stage III dyspnea. He was diagnosed with a calcified severe aortic stenosis. TTE showed an LVF of 30%, and a CT scan showed a porcelain aorta and a severe disease of the femoral arteries. The patient was contraindicated for surgery, and the heart team decided to give him a TAVR. The access strategy was strongly debated. The following approaches were ruled out: transfemoral (severe PAD), transaortic (porcelain aorta), transapical (LVF 30%), transcarotid (previous TEA), left axillary (ICD). Therefore, the right axillary approach was indicated.

The patient was placed in the supine position and intubated with a single-lumen endotracheal tube. The right axillary artery was dissected at the level of the delto-pectoral groove. An 18 Fr apical Certitude delivery system was inserted. An Edwards SAPIEN 3 26 mm valve was then implanted. The native valve was not heavily calcified and a balloon valvuloplasty was not done. The final result was optimal, with no perivalvular residual leak. The patient had an uneventful postoperative outcome and was discharged home on postoperative day three.

References

1. Ruge H, Lange R, Bleiziffer S et al. First successful aortic valve implantation with the CoreValve ReValving System via right subclavian artery access: a case report. Heart Surg Forum 2008;11:E323-4.
2. Andrew S.P. Sharp, Iassen Michev, and Antonio Colombo. First Trans-Axillary Implantation of Edwards Sapien Valve to Treat an Incompetent Aortic Bioprosthesis. Catheter and Cardiovasc Interv 2010 75:507–510.