Transapical Aortic Valve Implantation Without Angiography: Proof of Concept Enrico Ferrari, MD, Christopher Sulzer, MD, Carlo Marcucci, MD, Elena Rizzo,

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Transapical Aortic Valve Implantation Without Angiography: Proof of Concept Enrico Ferrari, MD, Christopher Sulzer, MD, Carlo Marcucci, MD, Elena Rizzo, MD, Piergiorgio Tozzi, MD, Ludwig K. von Segesser, MD The Annals of Thoracic Surgery Volume 89, Issue 6, Pages 1925-1932 (June 2010) DOI: 10.1016/j.athoracsur.2010.02.047 Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 (A) The cardiac computed tomographic scan shows the aortic valve annulus diameter and the distance between the valve and the coronary ostia. (B) The aortic three-dimensional computed tomographic scan reconstruction is helpful for the C-arm fluoroscopy preorientation in the theatre (perpendicular to the aortic valve plane). In order to avoid contrast injections (required in standard TA-TAVIs for the positioning of the fluoroscopic machine), a left lateral and a cranial position (in degrees) are calculated preoperatively and, subsequently, applied to the C-arm. (C) The picture taken from the fluoroscopy shows a Sapien implanted in the ideal landing zone. After the preoperative computed tomographic scan measurements, the fluoroscopy was preorientated adequately with no need for further adjustments and contrast injections: the stent-valve appears perpendicular to the native aortic valve and confirms the good C-arm preorientation. The Annals of Thoracic Surgery 2010 89, 1925-1932DOI: (10.1016/j.athoracsur.2010.02.047) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 The schema represents the intraoperative positioning of the fluoroscopy, oriented laterally and cranially, after the computed tomographic scan measurements. The Annals of Thoracic Surgery 2010 89, 1925-1932DOI: (10.1016/j.athoracsur.2010.02.047) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Schematic view from the fluoroscopy: the pigtail (yellow line) placed in the ascending aorta and advanced against the valve is a helpful landmark and should stay at the center of the screen. The valve calcifications visible (sometimes) under fluoroscopy also act as landmarks for the stent-valve positioning (blue line). The Annals of Thoracic Surgery 2010 89, 1925-1932DOI: (10.1016/j.athoracsur.2010.02.047) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Transesophageal echocardiogram allows for the positioning of the crimped valve across the native aortic annulus. (Key: landmarks are the hinge point of the aortic leaflets, the calcifications, the anterior mitral valve leaflet, and the Valsalva sinuses). The Annals of Thoracic Surgery 2010 89, 1925-1932DOI: (10.1016/j.athoracsur.2010.02.047) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 A transapical-transcatheter aortic valve implantation without angiography. (A) Images from the transesophageal echocardiogram showing the key phases of the procedure; the valve ballooning, the stent-valve positioning and the deployment. (B) The same key phases for the Sapien implantation are controlled by a preconfigured fluoroscopy. The red line represents the plane of the native aortic valve. The Annals of Thoracic Surgery 2010 89, 1925-1932DOI: (10.1016/j.athoracsur.2010.02.047) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions