Suprasternal Access for Transcatheter Aortic Valve Replacement for Self-Expanding Valves: A Simple Reliable Alternative Access A

Background: Transcatheter aortic valve replacement (TAVR) has proven be an effective and safe option for intermediate and high surgical risk patients. [1] Despite the continued advancement of valve technology and delivery systems, there still remains a cohort of the TAVR population who are not suitable for a transfemoral (TF) approach. [1] Several options for alternative access for TAVR have been described in the literature, including transcaval, axillary, subclavian, transcarotid, and suprasternal. [2-7] We have found suprasternal TAVR (SS-TAVR) as a safe and effective alternative to TF-TAVR and has now become our preferred alternative access route.

Preoperative Evaluation and Planning:
Patient Selection:
- Reserved for patients in whom TF access is not feasible (small size, toruosity, calcium)
- Also used for patients deemed high risk for vascular complications (abdominal or thoracic pathology or atheroma, or morbid obesity)
- Preoperative computerized tomography (CT) is paramount for planning

SS-TAVR Candidates are evaluated based on 4 criteria:

1. an innominate artery with an area free of calcium for sheath insertion
2. a minimum diameter of the innominate artery of 7 mm
3. limited angulation or tortuosity of the innominate artery and its attachment to the transverse arch
4. a minimum distance of 7-8 cm from the expected site of sheath insertion to the aortic annulus

- No strict contraindications (prior cardiac surgery, neck surgery, tracheostomy, carotid endarterectomy, mediastinal radiation all okay)
- Relative Contraindications: deformity of cervical spine which limits neck extension, large thyroid mass.

Patient Positioning and OR Setup
- General anesthesia and TEE required
- Bilateral non invasive cerebral saturation monitors
- Cephalad on OR table, supine, shoulder roll, maximal neck extension
- Right internal jugular vein vs femoral venous temporary pacer, right radial arterial line
- C-arm left side
- Left radial flush catheter
- Operator 1 right side, assistant left side, Operator 2 to the right of the Operator 1

Surgical Technique
- 3cm curvilinear incision similar to mediastinoscopy approach
- Platysma divided, dissection between sterno-thyroid muscles to pretracheal fascia.
- Inominate identified by palpation
- Division of right sterno-thyroid muscle
- Vessel loop is used to improved exposure and bring artery into operative field
- Two 4-0 prolene purse-strings-> artery punctured under direct visualization

TAVR Technique
- 7F sheath placed and flushed carefully
- Valve crossed using AL-1 catheter and straight wire
- Straight wire exchanged for a J wire and AL-1 exchanged for a pigtail
- Single Curved Lunderquist seated in apex
- Single dilation performed-> valve delivery system advanced
- Deployment of Evolut in standard fashion
- Minimal stored energy in the system, valve system tends ventricular on the Non-Coronary Cusp
- Careful hemostasis following removal of system
- Check cerebral saturations and ensure they are baseline

References

1. Leon MB, Smith CR, Mack MJ, et al. Transcatheter or Surgical aortic-valve replacement in intermediate-risk patients. NEJM, 2016;374:1609-20.

2. Grover FL, Vemulapalli S, Carroll JD, et al. 2016 Annula Report of the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. J Am Coll Cardiol 2017; 69:1215-30

3. Greenbaum AB, Babaliaros VC, Chen MY et al. Transcaval Access and Closure for Transcatheter Aortic Valve Replacement: A prospective investigation. J Am Coll Cardiol. 2017 Feb 7; 69(5):511-521.

4. Gleason TG, Schindler JT, Hagberg RC et al. Subclavian/Axillary Access for Self-Expanding Transcather Aortic Valve Repalcement Renders Equivalent Outcomes as Transfemoral. The Annals of Thoracic Surg. 2018; 105(2):477-483

5. Derby N, Delhaye C, Azmoun A et al. Transcarotid Transcathter Aortic Valve Replacement. JACC: Cardio Interventions. Oct 2016; 9 (20) 2113-2120
6. 
Kiser A, Caranasos T, Peterson M et al. Supraternal Transcatheter Aortic Valve Replacment in Patients with Marginal Femoral Access. Innovations Jan/Feb 2018 (13) 1-4.

7. Tayal R, Hawatmeh A, Thawabi M. et al. Percutaneous Transcatherter Aortic Valve Replacement. J Invasive Cardiol. Jun 2017; 29(6):E72-E73.

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