Balloon aortic valvuloplasty and subsequent device placement are then done through the 18-Fr sheath. Noniliofemoral Access Femoral access is our preferred insertion route. When this is not possible or safe, we use a noniliofemoral approach. Since the MDHVC is a CoreValve Trial site, we use the subclavian artery as our next option and, after that, a direct aortic option if subclavian artery insertion is not possible or safe. We have recently begun implantation of

the Edwards SAPIEN Valve, which may be inserted directly through the left ventricular apex via a small left thoracotomy or by the direct aortic approach. Inhibitors,research,lifescience,medical Subclavian Access The subclavian artery has recently become a site of access for TAVR.4, 5 The subclavian artery can be easily exposed in the deltopectoral groove of the anterior chest wall (Figure 1). We make a 3-cm incision in the deltopectoral groove that is carried down to the fibers of the pectoralis major, which are split along the lines of their fibers and retracted. The pectoralis minor Inhibitors,research,lifescience,medical can then be retracted or divided to expose

the subclavian artery. It is important to remember that the brachial plexus is just superior to the subclavian artery, and care should be taken in this dissection. The artery is surrounded with a vessel loop and a purse-string suture of 5-0 polypropylene placed in the anterior artery wall. The Inhibitors,research,lifescience,medical center of this purse string is punctured with a standard needle, and a soft, J-tip 0.035 wire is placed with a 6-Fr sheath placed over this. A catheter is placed over the wire into the ascending Inhibitors,research,lifescience,medical aorta, and then the soft wire is exchanged for a super stiff Amplatz wire. Dilators of 10 Fr, 12 Fr, 14 Fr, and 18 Fr are then passed over the stiff wire. This allows

the 18-Fr sheath to then be passed through the subclavian artery into the proximal ascending aorta. From this point the device insertion follows a standard procedure. In general, we have found it easier Inhibitors,research,lifescience,medical to insert and control the position of the device due to the proximity of the insertion site to the annulus. After the sheath is withdrawn at the end of the procedure, the purse-string suture is tied and additional sutures placed under direct vision as needed. Figure 1. Schematic drawing demonstrating the access site for a subclavian access. Two points should be noted when using the subclavian artery. Use of the right subclavian artery is possible Thalidomide but becomes technically difficult for device positioning if the aortic valve annulus is much more than 30 AZD0530 manufacturer degrees off the horizontal plane. Additionally, if a patent internal mammary artery (IMA) graft is present, ischemia must be carefully watched for since sheath obstruction or artery injury can limit flow during or after device placement. (To access a video of the subclavian access approach, visit www.debakeyheartcenter.com/journal/video.