1. How to Perform a Simplified Technique for Transapical Aortic Valve Implantations 
Pierre-Yves Litzler, MD, PhD, Hassiba Smail, MD 
Operative Techniques in Thoracic and Cardiovascular Surgery 
Volume 21, Issue 2, Pages (June 2016)
DOI: /j.optechstcvs
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2. Figure 1
Size selection of the Sapien 3 (S3) THV. Patients underwent preprocedural aortic root, coronary, and iliofemoral angiograms, transthoracic echocardiography (TTE), and chest tomography (CT) scan. Transcatheter heart valve (THV) sizing incorporates CT scan annular area assessment according to the manufacturer's computed tomography sizing guidelines. Annular area measurement can be easily determined with software such as OsiriX (Pixmeo, Geneva, Switzerland) (Fig. 1A) or 3mensio (Pie Medical Imaging, Maastricht, The Netherlands). Moreover, this software can easily determine the coronary artery ostia height (Fig. 1B) to avoid obstruction during the deployment of the valve. The measurement of the aortic annulus plane and the determination of its angulations on the CT scan can be transferred to the C arm to avoid multiple aortographies during the procedure.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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3. Figure 2
Hybrid operative room setup. The THV implantation is ideally performed in a hybrid room with a fixed high-resolution imaging system. Sufficient space is necessary to accommodate equipment in case of complications (use of cardiopulmonary bypass). The patient is positioned supine with a warming blanket on a radiographic operative table with arms padded and tucked. The primary operator is situated on the left side of the patient. A second operator is situated on the right of the primary operator to assist during the surgical preparation of the apex and to ensure sheath stability during the valve deployment. On the left side of the primary operator, a scrub nurse, who is familiar with surgical techniques and with the use of wires and catheters, will ensure a well-coordinated and secure procedure. The C arm must be placed on the right side of the patient. A defibrillator must be connected to the patient with radiolucent pads. A large table must be set up for THV crimping. Availability of surgical equipment for all possible adverse events (vascular or open heart surgery) should be prepared, including a fully primed cardiopulmonary bypass machine with peripheral and central cannulae. Coronary interventional equipment also must be available. TEE = transesophageal echocardiography.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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4. Figure 3
(A) Positioning of the patient. The patient is intubated with a single lumen tube and positioned in the supine position, exposing the entire chest including the axillary artery. Radiolucent defibrillator pads are attached and transesophageal echocardiography (TEE) is inserted. The patient must lay flat on the table without any roll under the shoulder or under the thorax to avoid modification of the angulations determined by the CT scan. Moreover, in case of a very lateral apex, the use of a swab beneath the heart during the procedure can lead to a greater risk of wire entanglement in the mitral subvalvular apparatus. Thus, it is crucial to have chest exposure up to the left midaxillary line on the left side to enlarge the incision if necessary. Both groins are exposed; in case of an emergency, a cardiopulmonary bypass is required. TEE = transesophageal echocardiography; TTE = transthoracic echocardiography.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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5. Figure 3
Continued (B) TTE apex localization. Before prepping and draping, we localize the left ventricular apex using TTE with an appropriate 4-chamber view to optimize the best surgical site of incision. This visualization of the aortic valve shows that the direction of the needle allows it to easily cross the aortic valve with the guidewire (arrow). The needle will have the same direction as the TTE probe.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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6. Figure 4
(A) Surgical exposure and apex preparation. A left anterior thoracotomy of 5 cm is performed through the fifth or sixth intercostal space depending on the position of the apex, predetermined by TTE. A rib spreader is used for optimal exposure. The spreader shoulder must be positioned toward the patient's left side to avoid the obstruction of the fluoroscopic field. The pericardium is opened and retracted with pericardial stay sutures and secured to the skin, except in the case of a redo patient if there is a risk of bleeding due to pericardial dissection. The retractor is then replaced inside the pericardium.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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7. Figure 4
Continued (B) Left ventricular apex localized by TEE-guided finger palpation. The site of puncture can be confirmed by finger palpation of the left ventricle (LV), easily visualized with TEE in a 2- or 4-chamber view. The ideal location is not the anatomical heart apex, but rather is lateral to the left anterior descending coronary artery and slightly toward the base. It is important to avoid left anterior descending and major diagonal coronary arteries. In most patients, there is an area that is free of fat at this location. Consider enlarging the incision if the apex exposure is not optimal. TEE = transesophageal echocardiography.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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8. Figure 5
(A) Left ventricular apex purse-string. Two adjacent purse-string sutures with an inner diameter of 2 cm are made using 2-0 polypropylene with large semicircular needles (MH 36) (Ethicon, Somerville, NJ) and 6 mm round felt thick pledgets (Bard, Covington, GA) on every bite. Each bite of the cardiac muscle should be deep. It is important that the bites are neither too shallow nor placed in the epicardium. For each purse-string, we typically use 4 bites with 4 pledgets. These pledgeted purse-strings secure the introduction of the sheath into the LV and, in case of bleeding, the 2 tourniquets can be gently tightened. Due to the perpendicular tension imposed on the myocardium, using mattress sutures is not recommended, particularly in frail patients.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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9. Figure 5
Continued (B) Insertion of ventricular pacing wires. A bipolar (or 2 monopolar) pacing wire is inserted through the myocardium in the middle of the 2 purse-strings and is attached to the skin to avoid secondary displacement during the rapid pacing. Epicardial pacing should be used to avoid complications linked to the puncture of the femoral vein (hematoma or vascular perforation) and the risk of right ventricular perforation with the pacing lead. Hemostasis should be ensured and heparin should be administered to achieve and maintain an Activated Clotting Time of ≥250 seconds during the procedure.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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10. Figure 6
(A) Determination of the direction of the left ventricular puncture. Before puncturing the LV, it is necessary to ensure that the defibrillator and the cardiopulmonary bypass are ready, the pacer capture is checked, the valve-positioning plan is determined, the heparin is administered, and the hemodynamic is stable. The C arm should be positioned in an anteroposterior view. To guide the direction of the left ventricular puncture, we place the metallic bar of a tourniquet on the chest, from the puncture site to the calcified aortic valve. The direction of the metallic bar (frequently aimed toward the right shoulder) easily directs the needle to cross the aortic valve with the guidewire.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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11. Figure 6
Continued (B) Left ventricular puncture. Under fluoroscopic guidance, we insert an 18-gauge needle in the center of the 2 purse-strings and ensure a good backflow. It is important that the needle avoids hitting the septum or a papillary muscle. A 180-cm in. soft J guidewire is advanced through the needle across the aortic valve toward the ascending aorta and away from the innominate artery to minimize the risk of vascular complication. We confirm with TEE that the guidewire is free of a mitral valve apparatus. If an increase of mitral regurgitation or a decrease of mitral leaflet mobility occurs, the guidewire must be pulled back, the direction of the needle must be changed, and the guidewire must be reinserted across the aortic valve under TEE assessment.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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12. Figure 7
(A) Pigtail insertion into the ascending aorta. After removing the needle, a pigtail is inserted over the soft guidewire into the LV and across the native valve. The pigtail is placed so the proximal hole of the catheter is just above the aortic valve. The C arm of the image intensifier is then placed to obtain the perpendicular deployment view determined with the CT scan. It is important to visualize the valve calcifications without interferences with the spine, mitral calcifications, or the chest retractor. The TEE probe must be retracted by 10-15 cm to avoid interferences with the aortography.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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13. Figure 7
Continued (B) Aortography. The pigtail is connected to the contrast media injector. Fifteen milliliters of contrast media is injected at a speed of 20 mL/s with an image rate of 15 fps (Fig. 7B). The view obtained must align the 3 hinges of the aortic valve leaflets in the same plane. It is important to visualize the valve calcifications and their positions in relation to the 3 hinges of the 3 leaflets. These calcifications will be the only reference points to guide the position of the Sapien 3 valve during the deployment. It is useful to keep this view on display as a “reference image” during the entire valve deployment. A line can be drawn at the 3 hinges of the leaflets in an imaging system or directly on the screen (with a dry erase marker) to help position the THV before delivering, particularly if the calcifications are not visible enough.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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14. Figure 8
Extra-stiff guidewire placed in the iliofemoral artery. The media injector is disconnected from the pigtail and a 260 cm × 0.035” Amplatz Extra-Stiff wire (Cook Medical, Bloomington, IN) is introduced into the pigtail. Under fluoroscopy, the pigtail with the wire is pushed to cross the aortic arch through the descending aorta until the iliofemoral artery. The pigtail is then removed while keeping the extra-stiff guidewire in place. This step ensures the stability of the guidewire and a stable valve deployment.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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15. Figure 9
(A) Introduction of the Certitude sheath. After removal of the pigtail under fluoroscopy, we insert the Certitude introducer sheath (Edwards life science, Irvine, CA) over the extra-stiff guidewire into the LV approximately to the 3-cm depth marker. The second operator must firmly stabilize the sheath in place and the sheath depth marker should be monitored throughout the procedure to avoid slipping in or out of the LV. The tip of the sheath is radiopaque and used to visualize the portion of the sheath introduced into the LV. The first operator removes the introducer from the sheath and maintains the guidewire in place. The hub port of the flush tube is open to de-air the sheath. It is important to maintain the guidewire in the center of the aortic valve during all these maneuvers. Excessive pressure on one of the aortic valve leaflets could lead to a major aortic insufficiency with hemodynamic instability. To avoid bleeding from the extremity of the sheath, it is necessary to coaxially align the guidewire within the sheath. In case of bleeding from the LV around the sheath, the purse-strings can be gently tightened.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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16. Figure 9
Continued (B) Insertion of the loader into the sheath. The delivery system is advanced over the extra-stiff guidewire, and the loader is engaged into the sheath until a click is heard. During the insertion, the sheath must be firmly maintained by the second operator with careful control of the sheath depth marker. The THV is advanced into the sheath 3-4 cm and crosses the hemostatic valve of the loader. The introducer sheath housing should be tapped lightly with the hand to release air bubbles. The button valve on the loader, placed in upper position, is depressed to completely de-air the loader.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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17. Figure 10
(A) Advancing THV to cross the native aortic valve. The THV is advanced through the sheath to cross the native aortic valve. The second operator must firmly stabilize the sheath in place and the sheath depth marker should be monitored throughout the procedure to avoid slipping in or out of the LV. If resistance is encountered during tracking into the LV, before reaching the native annulus, it is mandatory to control with TEE if the THV is not entangled with the mitral chordae. The guidewire and the THV must be centered coaxially to the native annulus and the ascending aorta. To achieve this, it may be necessary to track or push the guidewire to align with the center of the valve. Moreover, it is possible to flex the delivery system by rotating the ring placed on the delivery system handle. The delivery system will flex toward the “Edwards symbol” printed on the delivery system handle.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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18. Figure 10
Continued (B) Valve placement. The radiopaque marker in the middle of the THV must be aligned with the 3 hinges of the aortic valve leaflets. The reference image obtained with the aortography and the visualization of the calcification allows for perfect placement of the valve.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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19. Figure 10
Continued (C) Left ventriculography through the sheath. In case of doubt on the valve placement, it is possible to connect the contrast media injector to the tube flush of the sheath. An injection of 20 mL of contrast media at a speed of 20mL/s results in a left ventriculography with good visualization of the annulus plan. Then, the placement of the THV can be easily adjusted. The arcs means the hinges of the aortic valve leaflets and the dotted line shows the aortic annulus plan.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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20. Figure 11
(A) Monitoring and pacing during the valve deployment. When the THV is well placed, the target blood pressure must be between 100 and 130 mm Hg. Rapid pacing is started at an initial frequency of 180 bpm to obtain a systolic blood pressure around 60 mm Hg and a pulse pressure less than 10 mm Hg. If this target is not obtained, a frequency of 160  or 200 bpm must be tested. Once the blood pressure is stabilized, the ventilation is stopped and a last adjustment of the valve placement under fluoroscopy is secured. The THV is deployed after unlocking the Atrion inflation syringe.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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21. Figure 11
Continued (B) Inflate the balloon with the entire volume in the syringe. Empty the inflation syringe in a single, moderate, and steady inflation until the balloon is fully inflated. Hold the inflation for 5 seconds, deflate the balloon, stop the rapid pacing, and restore ventilation. During these steps, it is important that only the primary operator delivers the commands. After the deployment, the extra-stiff guidewire is retrieved, with the balloon left inside the THV to avoid tearing of the THV leaflets. The balloon is then pulled out of the THV and placed inside the loader, which can easily be removed from the sheath. The delivery of the THV is assessed with the TEE. It is not necessary and frequently uninformative to control the THV delivery with an aortography. Indeed, in case of a paravalvular leak, quantifying the leak with aortography is impossible. The complete deployment of the Sapien 3 outer sealing cuff takes at least 15 minutes. Moreover, repeated injection of contrast media in frail patients could lead to postoperative renal insufficiency.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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22. Figure 12
Surgical closure. The sheath is removed from the LV and the tourniquets are gently tightened to obtain hemostasis. Blood pressure should be under 130 mm Hg before removing the sheath to avoid ventricular rupture. Rapid pacing during these steps must be considered only in case of a very frail ventricle. Protamine is then given, and once a perfect hemostasis is obtained (typically after 5 minutes), the knots of the 2 purse-strings can be tightened. A small soft drain is inserted into the pleural space and a Redon drain is inserted into the pericardium. An analgesia catheter is inserted into the subcutaneous intercostal space. The pacing wire is left in place and secured to the skin. The thoracotomy is then closed in standard fashion.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
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