Apical Access Management in Transapical Transcatheter Mitral Valve Replacement.

Background
The role of the surgical technique and anatomy in transapical mitral valve replacement (TA-TMVR) are scarcely investigated.Methods
Computed tomography scans, surgical reports and planning slides of 127 patients undergoing TA-TMVR with the Tendyne valve system at 15 centers, participating at a European observational study, were retrospectively analyzed and compared between patients with (cohort A) and without (cohort B) apical access complications (AAC).Results
A total of 8 (6.3%) AAC were recorded, of which 7/8 were observed in the first 10 patients of the respective center. Patients with AAC showed a trend to a thinner myocardium at the target access compared to those with regular access (median 4.4 vs. 6.1mm, p=0.086). Technical difficulties along with AAC were reflected by a significant longer procedural time (median 180 vs. 123min, p=0.011), higher rates of circulation support (50% vs. 0%, p<0.001), valve retrieval (38% vs. 3%, p=0.005) and bailout full sternotomy (13% vs. 0%, p=0.063). AAC were related with an intraprocedural mortality and in-hospital mortality rate of 25% (vs. 0%, p=0.010) and 50% (vs. 7%, p=0.003), respectively. Totally, 8 of 12 in-hospital deaths were attributed to AAC and/or sepsis. AAC significantly increased the risk for 30-day (adjusted OR 19.5, CI 2.19-178.3, p=0.008) and in-hospital mortality (adjusted HR 9.00, CI 1.95-41.42, p=0.005).Conclusions
Access complications in TA-TMVR 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 AAC and improve outcome.