Entwicklung der transapikalen Transkatheter Aortenklappenimplantation am Universitätsklinikum Marburg unter besonderer Berücksichtigung von Zeit und Klappentyp

The calcified aortic stenosis is a chronic progressive disease, which is third in rank of all cardiovascular diseases after the arterial hypertension and the coronary heart disease. The conventional open aortic valve replacement was until recently the golden standard in the treatment of the calcific aortic stenosis, but for patients over the age of 80 or with an ejection fraction of under 40% it presented as too much of a risk and could rarely be performed in these cases. The transapical way ot the procedure that is discussed here as well as the transfemoral approach of the catheter based aortic valve replacement is now a valid alternative to the conventional aortic valve replacement for high risk patients with a calcific aortic valve stenosis. To decide in favor of the TAVI procedure the patient has to present with advanced age, as well as various other co-morbidities that would markedly increase the risk of a conventional operative treatment. In these cases, the indication for the transapical approach is given if the patient has a severe arterial occlusive disease, which would make the preferred transfemoral approach impossible. There are 2 different types of aortic valve prostheses that are discussed here: The Edwards Sapien XT and the Edwards Sapien 3 balloon expandable bioprostheses. This paper mainly deals with the comparison of various postoperative complications after a transapical TAVI procedure in 3 different time periods of time: 2009-2011, 2012-2014,2015- 2016. Furthermore, we are looking at 2 types of aortic valve prosthesis used at the University Clinic of Marburg (Edwards Sapien XT, Edwards Sapien 3) and the possible correlations between type of prosthesis and the complications. The average age of the patients was 80,5 years and most of them were female. A postoperative dislocation was mainly present during the early phase of the transapical TAVI procedure at the University Clinic of Marburg. After some years when the procedure got established at the clinic the incidence of dislocations dropped markedly (group 1: 74%; group 2: 2,4%; group 3: 0%). Comparing the incidence of postoperative bleeding in the different time periods, a significant increase could be observed. The reason still has to be investigated (group 1: 0%; group 2: 8,3%; group 3: 13,6%). Regarding the occurrence of a postoperative delirium, there was a statistically insignificant increase between group 2 and group 3. (group 2: 7,1%; group 3: 18,2%). A residual aortic insufficiency at discharge was detected in 34,1% of the whole patient cohort. Of these patients only 2,1% had a moderate to high grade aortic insufficiency and 31,1% of the patients only had a trivial or mild residual aortic insufficiency. If you compare these numbers in the time periods, you can observe a markedly, statistically significant decrease of the incidence of residual aortic insufficiency at discharge of the patient (group 1: 35,5%; group 2: 40,5%; group 3: 4,5%). This decline of overall cases of patients with a residual aortic insufficiency could be explained by the transition from the use of the Edwards Sapien XT (38,3%) to the Edwards Sapien 3 (0%) bioprosthesis after the year 2011. The average length of stay of patients on the intensive care unit was 4,04 days and the time of intubation for most patients (68,9%) was not longer than one day. The overall 30-day mortality was 6,8%. In the different time periods the mortality was 10,5% for group 1, for group 2 it was 2,4% and for group 3 it was 4,5%. With our data in mind we can say that the development of the transapical TAVI procedure at the University Clinic of Marburg is very promising and therefore can still be considered as a valid alternative therapeutic option for high-risk patients with a calcific aortic stenosis.