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.