A Challenging Case of Suprasternal Aortic Valve Implantation

Objectives: Alternatives to transfemoral transcatheter aortic valve replacement (TAVR) include transapical, transaortic or transsubclavian approach. Recently access sites have been expanded to transcarotid, transcaval and suprasternal. We present a case of suprasternal TAVR using the Suprasternal Aortic Access System (SuprAA System, Aegis Surgical Ltd, Dublin, Ireland) in a non-transfemoral patient with a goiter and previous tracheotomy.

Methods: A 62-year old male presenting with a symptomatic aortic stenosis was scheduled for TAVR due to a high surgical risk (renal insufficiency (creatinine 1.77mg/dl), COPD GOLD III, peripheral artery disease (PAD), poor left ventricular function (45%), coronary artery disease, immobility due to a massive abdominal hernia, STS-Score 5.4%, log EuroSCORE 8.22%). The patient had had a previous tracheotomy due to multiple organ failure following gastric perforation. Furthermore he presented with a goiter not reaching below the sternum. CT-imaging showed an aortic valve annulus perimeter of 8.7cm, an area of 596mm² as well as severe PAD. The patient was planned for a suprasternal TAVR implantation.

Results: Under general anesthesia the patient was placed in a supine position with the head turned to the right allowing optimal exposure of neck and chest. A 4cm long transverse incision was made above the sternal notch. Respecting vessels, the area between the sternohyoid muscles was prepared down to the pretracheal fascia. Blunt dissection underneath the sternum revealed very firm tissue and an innominate artery rotated to the right. Due to the scaring of the tissue, the SuprAA device could not be advanced up to the aortic arch. The innominate artery was then chosen as the access site. Using endoscopic instruments purse string sutures were placed and a 21 Fr transapical Edwards Sapien 3 sheath was advanced. A 29mm Edwards Sapien 3 prosthesis was implanted in the usual manner. After sheath removal and closure of the sutures, the SuprAA device was removed. A soft drain was placed and the skin was closed in two layers. The patient was extubated shortly after the procedure, reported no pain and was moved to the normal ward on the first postoperative day.

Conclusion: Even though this patient presented with a history of previous tracheotomy and struma, which most likely caused the shifted position of the innominate artery, this access proved to be safe and feasible. The patient expressed no pain and recovered quickly.