A novel method of ventricular closure following transapical access

Abstract

Aim: Left ventricular direct access and sheath placement through a minithoracotomy has been utilized to allow minimally invasive valvular surgery. One potential problem encountered is the closure of the ventricular puncture incision in a beating heart. Our aim was to develop a sutureless closure technique that does not leave behind a foreign body exposed on the endocardial surface. Materials & methods: We sought to evaluate this concept in vivo in the porcine model. Thoracotomy was performed with exposure of the beating heart. A total of six Fr sheaths were placed in the transapical territory in the left and right ventricle with fluoroscopy confirming sheath placement. The incisions were then closed using three types of commercially available femoral vascular closure systems (AngioLink™, StarClose™ and Mynx™). Results: One animal had one device placed in the left and right ventricle and closure was then immediately observed intraoperatively (AngioLink). Another animal had five devices (StarClose) placed in the left ventricle and one in the right ventricle, with closure observed within 1 min of application. A third animal had the sheath removed and spontaneous closure then observed at two sites. These two sites continued to bleed for 2–3 min. The same animal had an application of six Mynx devices at sheath sites using an extravascular bio-inert sealant. One site failed and the five others were immediately successful. Histopathology evaluation confirmed no evidence of device exposure on the endovascular surface in the first two animals. The Mynx device sealant was present on the endocardial surface at closure sites postmortem. Conclusion: We have introduced a new concept of using vascular closure systems for closing ventricular wall stab incisions after transapical surgery. We intend to expand the scale of animal studies and evaluate the device for any modifications in the mechanism or technique for ultimate use in human subjects.