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In recent years, catheter-based aortic valve interventions have become established procedures for the treatment of high-risk and advanced age patients with aortic valve pathologies. One of the limitations of the widespread applicability of this procedure is the annulus size. Until recently, no prosthesis was available to treat patients with a large annulus. We report on a patient with high-grade aortic stenosis (AS) and a 27-mm annulus, who underwent transapical implantation (TAP) of an Edwards SAPIEN® 29-mm prosthesis (Edwards LifeScience, Irvine, CA, USA). Due to insufficient dilation of his heavily calcified, functionally bicuspid aortic valve leaflets during balloon aortic valvuloplasty (BAV), the TAP prosthesis did not anchor adequately. This was determined during follow-up as he developed progressive aortic insufficiency and orthopnea, and an echocardiography revealed that the valve had been displaced into the LVOT. A conventional aortic valve replacement and ascending aorta replacement were performed, at which time the TAP prosthesis was removed. The patient recovered uneventfully, and was discharged with a well-functioning aortic bioprosthetic valve and in good general condition.

Background: Impaired respiratory function is believed to be a risk factor for transapical aortic valve implantation (TA-AVI). The purpose of this study was to investigate the incidence, predictors and impact of acute and chronic respiratory failure (ARF and CRF) on procedural success and outcome. Methods: 350 consecutive ‘high-risk’ patients, age 81.8 6.4 years, 66.3% female, were included during a 4-year period. Preoperative estimated FEV1 was 91.9 33.6%. Mean logistic EuroSCORE was 31.0 15.9% and mean STS-Score 12.0 7.7%. An uniand multivariate logistic regression analysis was performed. Results: Regarding the postoperative respiratory outcome, ARF occurred in 14.9% and interstitial lung disease (OR 23.40, p 0.01), transfusion 4 RBC units (OR 15.35, p 0.001), brief reactive psychosis (OR 8.39, p 0.001), age 80 yrs (OR 3.66, p 0.035) and vital capacity 60% (OR 3.23, p 0.025) were independent risk factors for this event. Postoperative re-intubation was required in 17.1%. Vital capacity 60% (OR 2.94, p 0.046) and transfusion 4 RBC units (OR 16.00, p 0.001) were independent risk factors for CRF. Short-term and long-term survival was explicitly lower in the ARF, CRF and re-intubation groups (p 0.001 each). Conclusions: Interstitial lung disease, age 80 yrs and vital capacity 60% are preoperative risk factors for impaired respiratory outcome. Further studies will define if the same risk factors can be expected using a transfemoral approach.