Suprasternal Access for Transcatheter Aortic Valve Replacement for Self-Expanding Valves: A Simple Reliable Alternative Access A

Background: Transcatheter aortic valve replacement (TAVR) has proven be an effective and safe option for intermediate and high surgical risk patients. [1] Despite the continued advancement of valve technology and delivery systems, there still remains a cohort of the TAVR population who are not suitable for a transfemoral (TF) approach. [1] Several options for alternative access for TAVR have been described in the literature, including transcaval, axillary, subclavian, transcarotid, and suprasternal. [2-7] We have found suprasternal TAVR (SS-TAVR) as a safe and effective alternative to TF-TAVR and has now become our preferred alternative access route.



Preoperative Evaluation and Planning:


Patient Selection: 
-

Reserved for patients in whom TF access is not feasible (small size, toruosity, calcium)
- Also used for patients deemed high risk for vascular complications (abdominal or thoracic pathology or atheroma, or morbid obesity)
- Preoperative computerized tomography (CT) is paramount for planning 



SS-TAVR Candidates are evaluated based on 4 criteria:
1.) an innominate artery with an area free of calcium for sheath insertion
2.) a minimum diameter of the innominate artery of 7 mm
3.) limited angulation or tortuosity of the innominate artery and its attachment to the transverse arch
4.) a minimum distance of 7-8 cm from the expected site of sheath insertion to the aortic annulus
- No strict contraindications (prior cardiac surgery, neck surgery, tracheostomy, carotid endarterectomy, mediastinal radiation all okay)
- Relative Contraindications: deformity of cervical spine which limits neck extension, large thyroid mass. 



Patient Positioning and OR Setup
-

General anesthesia and TEE required
- Bilateral non invasive cerebral saturation monitors
- Cephalad on OR table, supine, shoulder roll, maximal neck extension
- Right internal jugular vein vs femoral venous temporary pacer, right radial arterial line
- C-arm left side
- Left radial flush catheter 
- Operator 1 right side, assistant left side, Operator 2 to the right of the Operator 1



Surgical Technique
-

3cm curvilinear incision similar to mediastinoscopy approach 
- Platysma divided, dissection between sterno-thyroid muscles to pretracheal fascia. 
- Inominate identified by palpation
- Division of right sterno-thyroid muscle
- Vessel loop is used to improved exposure and bring artery into operative field
- Two 4-0 prolene purse-strings-> artery punctured under direct visualization



TAVR Technique
-

7F sheath placed and flushed carefully
- Valve crossed using AL-1 catheter and straight wire 
- Straight wire exchanged for a J wire and AL-1 exchanged for a pigtail
- Single Curved Lunderquist seated in apex
- Single dilation performed-> valve delivery system advanced
- Deployment of Evolut in standard fashion 
- Minimal stored energy in the system, valve system tends ventricular on the Non-Coronary

Cusp
-

Careful hemostasis following removal of system
- Check cerebral saturations and ensure they are baseline