The IX t h Makassed Medical Congress - American University of Beirut

470 Valvular, Myocardial, Pericardial, and Cardiopulmonary Disease
Outcomes
is crossed antegradely, dilated, and then stented under rapid pacing as in
the transfemoral route, except that the Edwards Sapien valve is mounted
appropriately with its sleeve on the ventricular side of the valve.
• The transseptal approach (Fig. 1C) is somewhat more challenging for
an interventionalist who may not be accustomed to working in the left
atrium. There is some danger of damaging the mitral valve with the stiff
wire if adequate slack is not maintained during the procedure. Femoral
venous access is obtained and a balloon-tipped catheter advanced
into the left ventricle after transeptal puncture. The aortic valve is then
crossed with a wire or the catheter itself. The wire is then snared via
femoral arterial access, and a catheter is passed to the aortic valve for
adequate control of the wire. Valvuloplasty and valve replacement steps
are similar to those of other approaches.
• Percutaneous AVR was fi rst performed via transseptal access by
Dr. Allan Cribier in Rouen, France in April 2002. The initial experience
from compassionate use of the balloon-expandable 23-mm valve
from the antegrade approach was reported in the I-REVIVE (Initial
Registry of Endovascular Implantation of Valves in Europe) and
RECAST (Registry of Endovascular Critical Aortic Stenosis Treatment).
The procedural success rate was 75%, with a 30-day mortality
rate of 23%. Moderate to severe aortic regurgitation was reported
in 63% of patients, partly as a result of the valve size. Concerns also
were raised about the procedural challenges posed by the transseptal
puncture and the potential for damage to the mitral valve apparatus
by the stiff wire and aortic prosthesis.
• Signifi cant advances were made by Dr. John Webb in Vancouver in
implanting this valve retrogradely via the transfemoral route. His team
successfully implanted the Cribier-Edwards valve in 14 of 18 patients
who had previously been deemed unsuitable for SAVR [16]. The measured
aortic valve area increased from 0.6 ± 0.2 to 1.6 ± 0.4 cm 2 and
remained stable at 1-month follow-up [16]. The early mortality rate
was 11% (2 of 18), and short-term survival was 89% (16 of 18) at a
mean follow-up of 75 days [16]. The same group reported both short-
and long-term outcomes in an extended cohort of 50 patients [24••].
Procedural success increased from 76% in the fi rst 25 patients to 96%
in the second [25], and 30-day mortality fell from 16% to 8%. Further,
this series demonstrated that paravalvular leak is not a major issue if
the valve size is larger than the annulus (ie, a 23-mm valve for a 17- to
21-mm annulus and a 26-mm valve for a 21- to 24-mm annulus). It also
was apparent that the success rate was very dependent on proper patient
selection, with the main focus on vascular access to prevent procedural
vascular complications.
• Lichtenstein et al. [25] successfully implanted the Cribier-Edwards valve
using the apical approach and fl uoroscopic guidance in all seven patients
in whom they attempted the procedure. All patients were deemed by
an experienced operator to be unsuitable for SAVR and also for percutaneous
transfemoral percutaneous heart valve implantation because
of severe aortoiliac disease [25]. Four of the seven patients were alive
at 6 months [26]. Subsequently, Walther et al. [27] published their data
describing implantation of the Cribier-Edwards valve in 30 elderly patients.
At a mean follow-up of 108 days, 86% of the patients reportedly
were doing well [27].
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