We present the case of a young man with a prior homograft root replacement and a subsequent transcatheter aortic valve-in-valve, who presented with a root pseudoaneurysm and severe aortic regurgitation due to valve degeneration from endocarditis. The surgical procedure involved the explant of transcatheter aortic valve implantation prosthesis using a snare technique, removal of the homograft and a subannular Bentall procedure. This case illustrates the technical challenges and the "lifetime management" strategy required for complex redo aortic interventions in younger patients.

Background. The growing experience in minimally invasive techniques, supported by outstanding outcomes and excellent surgical exposure of the entire proximal thoracic aorta via ministernotomy, has motivated surgeons to apply this approach to more challenging procedures such as aortic root and arch treatment. Methods. From September 2016 to April 2024, 243 consecutive patients underwent proximal aortic surgical treatment through the ministernotomy approach at the Cardiac Surgery Unit of the Lancisi Cardiovascular Center of Ancona- Polytechnic University of Marche, Italy. In all cases, a preoperative computed tomography scan was performed. Results. The mean age of the population was 65 +/- 12 years, and 176 patients (72%) were male. Aortic valve disease occurred in 66.9% of cases (n=85) with significant aortic valve regurgitation or stenosis in 127 (52%) and 44 (18%) patients, respectively. Bicuspid aortic valve was found in 29% of patients (n=70). Surgical procedures included aortic root operations (n=88) using Bentall (n=64) or David (n=24) technique, isolated replacement of the ascending aorta (n=73), and combined treatment: replacement of the ascending aorta and the aortic valve (n=82). The 30-day mortality and stroke rate was 0.4%. In 132 patients (54%), extubation occurred within the first 6 h after surgical treatment. The median hospital stay was 7 days with 48% (n=107) of patients discharged home without need for any cardiac rehabilitation. Conclusions. Minimally invasive thoracic aortic surgery can be performed successfully at specialized cardiac surgery centers. Preoperative careful and accurate analysis of patient's computed tomography scan is essential to promote patient-tailored planning and promote optimal surgical exposure.

BACKGROUND:The growing experience in minimally invasive techniques, supported by outstanding outcomes and excellent surgical exposure of the entire proximal thoracic aorta via ministernotomy, has motivated surgeons to apply this approach to more challenging procedures such as aortic root and arch treatment. METHODS:From September 2016 to April 2024, 243 consecutive patients underwent proximal aortic surgical treatment through the ministernotomy approach at the Cardiac Surgery Unit of the Lancisi Cardiovascular Center of Ancona - Polytechnic University of Marche, Italy. In all cases, a preoperative computed tomography scan was performed. RESULTS:The mean age of the population was 65 ± 12 years, and 176 patients (72%) were male. Aortic valve disease occurred in 66.9% of cases (n=85) with significant aortic valve regurgitation or stenosis in 127 (52%) and 44 (18%) patients, respectively. Bicuspid aortic valve was found in 29% of patients (n=70). Surgical procedures included aortic root operations (n=88) using Bentall (n=64) or David (n=24) technique, isolated replacement of the ascending aorta (n=73), and combined treatment: replacement of the ascending aorta and the aortic valve (n=82). The 30-day mortality and stroke rate was 0.4%. In 132 patients (54%), extubation occurred within the first 6 h after surgical treatment. The median hospital stay was 7 days with 48% (n=107) of patients discharged home without need for any cardiac rehabilitation. CONCLUSIONS:Minimally invasive thoracic aortic surgery can be performed successfully at specialized cardiac surgery centers. Preoperative careful and accurate analysis of patient's computed tomography scan is essential to promote patient-tailored planning and promote optimal surgical exposure.

Background. The introduction of transcatheter procedures has focused on patient expectations for treatments with a less invasive approach and faster recovery. The aim of this study was to assess the short- and medium-term results in patients who underwent trans-axillary mitral valve repair with application of the ultra-fast-track protocol. Methods. Data from 431 patients undergoing isolated trans-axillary mitral valve repair or associated with tricuspid valve treatment between January 2018 and December 2023 were prospectively collected. Results. The mean age of the population was 63 +/- 11 years and the average EuroSCORE II was 1.21 +/- 1%. Mitral valve repair for degenerative mitral regurgitation was performed in 93.3% of cases. In 52 cases (12.6%) concomitant tricuspid valve repair was performed. The 30-day mortality rate was 0.2% (n=1), the postoperative stroke rate was 0.2% (n=1). A total of 351 patients (81.4%) were extubated within 6 h of the procedure; in 218 cases (50.6%) extubation occurred in the operating room, at the end of the surgical treatment. Overall, 70.8% (n=305) of patients left the intensive care unit on the first postoperative day; 222 patients (51.6%) were discharged home without the need for any further rehabilitation. Postoperative mitral regurgitation was absent/negligible in 97% of cases (n=418). Survival at 1 year and 5 years was 98.9% and 97.9%, respectively. Conclusions. The trans-axillary approach for mitral valve repair was associated with low rates of in-hospital mortality and postoperative complications. The application of our ultra-fast-track protocol in more than 80% of cases allowed early extubation, short intensive care unit stay and reduced hospitalization with a high rate of patients able to be discharged home with no need of any further period of rehabilitation. The medium-term outcomes support the safety and efficacy profile of the trans-axillary approach.

Razionale. L’introduzione delle procedure transcatetere ha posto l’attenzione sulle aspettative dei pazienti per trattamenti con approccio meno invasivo e più rapido recupero funzionale. Lo scopo di questo studio è mostrare i risultati a breve e medio termine della chirurgia riparativa mitralica con approccio trans-ascellare e applicazione del protocollo “ultra-fast-track”. Materiali e metodi. Sono stati raccolti in modo prospettico i dati di 431 pazienti sottoposti con approccio trans-ascellare a riparazione isolata della valvola mitrale o associata al trattamento della valvola tricuspide tra gennaio 2018 e dicembre 2023.Risultati. L’età media della popolazione era di 63 ± 11 anni con EuroSCORE II di 1.21 ± 1%. La riparazione della valvola mitrale per insufficienza mitralica degenerativa è stata eseguita nel 93.3% dei casi. In 52 casi (12.6%) è stata effettuata la riparazione della valvola tricuspide come intervento combinato. La mortalità registrata a 30 giorni è stata di 0.2% (n=1), il tasso di ictus postoperatorio di 0.2% (n=1). L’81.4% dei pazienti (n=351) è stato estubato entro 6 h dall’intervento; in 218 casi (50.6%) l’estubazione è avvenuta in sala operatoria, immediatamente dopo la fine dell’intervento. Il 70.8% (n=305) dei pazienti è stato dimesso dalla terapia intensiva in prima giornata postoperatoria; per 222 pazienti (51.6%) la dimissione è avvenuta a domicilio senza necessità di ulteriore riabilitazione. L’insufficienza mitralica post-trattamento era assente/trascurabile nel 97% dei casi (n=418). La sopravvivenza ad 1 anno è stata del 98.9%, mentre a 5 anni del 97.9%. Conclusioni. L’approccio trans-ascellare per la riparazione della valvola mitrale è stato associato a un basso tasso di mortalità intraospedaliera e complicanze postoperatorie. L’applicazione del nostro protocollo “ultra-fast-track” in più dell’80% dei casi, ha reso possibile estubazione e mobilizzazione precoce, ha ridotto il tempo di degenza in terapia intensiva e l’ospedalizzazione con possibilità di dimissione a domicilio senza necessità di ulteriore riabilitazione. I risultati a medio termine confermano il profilo di sicurezza ed efficacia dell’approccio trans-ascellare.

Razionale. La crescente esperienza nelle tecniche mini-invasive, supportata sia dagli ottimi risultati e sia dall’eccellente esposizione chirurgica dell’intera aorta ascendente tramite ministernotomia, ha motivato i chirurghi ad utilizzare tale approccio anche in procedure più complesse quali il trattamento della radice e dell’arco aortico.Materiali e metodi. Da settembre 2016 ad aprile 2024 sono stati arruolati 243 pazienti sottoposti a trattamento chirurgico dell’aorta prossimale con approccio ministernotomico presso l’Unità di Cardiochirurgia del Centro Cardiovascolare Lancisi di Ancona - Università Politecnica delle Marche. In tutti i casi è stata eseguita un’angio-tomografia computerizzata dell’aorta toraco-addominale preoperatoria.Risultati. L’età media della popolazione era di 65 ± 12 anni e 176 pazienti (72%) erano di sesso maschile. La patologia valvolare aortica era presente nel 66.9% dei casi (n=85) con riscontro di insufficienza o stenosi valvolare più che moderata rispettivamente in 127 (52%) e 44 (18%) casi. La valvola aortica appariva di morfologia bicuspide nel 29% dei pazienti (n=70). Le procedure chirurgiche comprendevano il trattamento della radice aortica (n=88) utilizzando la tecnica di Bentall (n=64) o David (n=24), la sostituzione isolata dell’aorta ascendente (n=73) e la sostituzione combinata dell’aorta ascendente e della valvola aortica (n=82). Il tasso di mortalità a 30 giorni e di ictus è stato dello 0.4%. In 132 casi (54%) l’estubazione è avvenuta entro le prime 6 h dopo il trattamento chirurgico. La mediana di degenza ospedaliera è stata di 7 giorni con il 48% (n=107) dei pazienti dimesso a domicilio senza necessità di alcuna riabilitazione cardiorespiratoria successiva. Conclusioni. La chirurgia dell’aorta prossimale può essere eseguita in maniera sicura ed efficace attraverso la ministernotomia superiore in centri cardiochirurgici specializzati. Un’attenta e accurata analisi dell’anatomia aortica del paziente all’imaging preoperatorio è essenziale per consentire un’efficace pianificazione del trattamento e favorire un’esposizione chirurgica ottimale.

BACKGROUND:The introduction of transcatheter procedures has focused on patient expectations for treatments with a less invasive approach and faster recovery. The aim of this study was to assess the short- and medium-term results in patients who underwent trans-axillary mitral valve repair with application of the ultra-fast-track protocol. METHODS:Data from 431 patients undergoing isolated trans-axillary mitral valve repair or associated with tricuspid valve treatment between January 2018 and December 2023 were prospectively collected. RESULTS:The mean age of the population was 63 ± 11 years and the average EuroSCORE II was 1.21 ± 1%. Mitral valve repair for degenerative mitral regurgitation was performed in 93.3% of cases. In 52 cases (12.6%) concomitant tricuspid valve repair was performed. The 30-day mortality rate was 0.2% (n=1), the postoperative stroke rate was 0.2% (n=1). A total of 351 patients (81.4%) were extubated within 6 h of the procedure; in 218 cases (50.6%) extubation occurred in the operating room, at the end of the surgical treatment. Overall, 70.8% (n=305) of patients left the intensive care unit on the first postoperative day; 222 patients (51.6%) were discharged home without the need for any further rehabilitation. Postoperative mitral regurgitation was absent/negligible in 97% of cases (n=418). Survival at 1 year and 5 years was 98.9% and 97.9%, respectively. CONCLUSIONS:The trans-axillary approach for mitral valve repair was associated with low rates of in-hospital mortality and postoperative complications. The application of our ultra-fast-track protocol in more than 80% of cases allowed early extubation, short intensive care unit stay and reduced hospitalization with a high rate of patients able to be discharged home with no need of any further period of rehabilitation. The medium-term outcomes support the safety and efficacy profile of the trans-axillary approach.

We present the case of an asymptomatic 40-year-old male patient who underwent a transoesophageal echocardiography examination for further evaluation of aortic regurgitation. On physical examination, an occasional diastolic murmur was detected. Transthoracic echocardiography demonstrated aortic regurgitation that was difficult to quantify accurately. A type F quadricuspid aortic valve was subsequently identified and confirmed by three-dimensional transoesophageal echocardiography.

Introduction: Neurological complications pose significant risks in coronary artery bypass grafting (CABG). This study explores the potential benefits of preoperative chest computed tomography (CT) in optimizing outcomes and reducing neurological events in high-risk CABG patients. Methods: From January 2017 to June 2023, a retrospective cohort study of CABG patients categorized groups based on preoperative chest CT use. Multivariate analysis evaluated the associations between CT imaging and patient characteristics, followed by propensity match analysis to balance preoperative features across groups. Results: The study included 1786 patients, with 435 having undergone preoperative CT and 1351 without. Propensity matching created two well-balanced groups of 413 patients each. At multivariate analysis, CT patients were elderly (71.1 +/- 8.9 years; p = 0.03) with a higher incidence of pulmonary disease (19.5%; p < 0.01), peripheral arterial disease (29.2%; p < 0.01), and previous cerebrovascular disease (23.4%; p = 0.02). In the matched CT cohort, the perioperative cerebral stroke rate was 0.7% (vs. 1.9% in without preoperative CT [WCT] cohort; p = 0.223), and the 30-day mortality rate was 0.2% (vs. 1.7% in WCT cohort; p = 0.069). Patients who had a preoperative CT study presented a higher prevalence of porcelain aorta (6.3% vs. 1.5%; p = 0.0003) and required more often a no-touch aorta procedure (20.3% vs. 14.5%; p = 0.035). Conclusions: Patients undergoing preoperative chest CT before CABG were typically older and had systemic atherosclerosis and pulmonary disease. Propensity-matched analysis indicated low mortality and perioperative cerebral stroke rates in these high-risk patients. These findings support the integration of chest CT into preoperative evaluations for high-risk patients to develop tailored strategies in coronary artery bypass surgery.

Early postoperative left ventricular dysfunction due to myocardial stunning can negatively affect outcomes in patients with mitral regurgitation undergoing mitral valve surgery. The aim of this study was to evaluate the impact of the ultra-short acting beta blocking agent esmolol, administered after the anesthesia induction and before aortic cross-clamping, on myocardial protection and on postoperative clinical course in patients undergoing mitral valve surgery for mitral regurgitation. Patients undergoing mitral valve surgery for primary mitral regurgitation were analyzed according to the use or not of esmolol. Clinical, procedural and laboratory data were collected. A 1:2 propensity score matching analysis (esmolol vs. control) was performed to adjust for baseline differences. The primary endpoint was the occurrence of postoperative low cardiac output syndrome. Out of 322 patients (age: 66 f 11 years; 140 women) with mitral regurgitation undergoing mitral valve surgery, 99 received esmolol while 223 patients did not. Low cardiac output syndrome occurred significantly less frequently in patients treated with esmolol as compared to patients not receiving it (12.1% vs. 33.2%, p < 0.001 before matching and 13.0% vs. 30.4%, p = 0.006 after matching). Peak postprocedural creatin kinase MB release was lower in patients treated with esmolol as compared to those not treated with esmolol (57 f 30 g/mL vs. 82 f 70 mu g/mL, p < 0.001 before matching and 57 f 31 g/mL vs. 83 f 79 mu g/mL, p = 0.008 after matching). Acute kidney injury and length of intensive care unit stay were reduced in the esmolol group both before and after matching. In conclusion esmolol administered after anesthesia induction and before aortic cross-clamping could improve myocardial protection in patients with mitral regurgitation undergoing mitral valve surgery.

Surgical aortic valve replacement (SAVR) in female patients has been associated with higher mortality (up to 3.3–8.9%) and postoperative complication rates when compared with their male counterparts. In recent years, TAVI has been shown to provide a greater benefit than SAVR in women. We sought to assess the early outcomes of the contemporary aortic valve intervention practice (surgical and transcatheter) in patients referred to our cardiac surgery unit. The data of consecutive patients who underwent isolated aortic valve intervention for aortic valve stenosis during the 2018–2022 period were retrieved from our internal database. Several preoperative, intraoperative, and postoperative variables were analyzed, including the predicted risk of a prosthesis–patient mismatch. Nine hundred and fifty-five consecutive patients—514 women and 441 men—were included. Among them, 480 patients—276 female and 204 male—received a transcatheter procedure, and 475—238 women and 237 men—had conventional SAVR. The women were older and had higher EuroSCORE II, while the male patients presented a higher incidence of cardiovascular comorbidities. There was no difference in mortality or major postoperative complication rates after either the surgical or transcatheter procedures between the female and male populations. The availability and targeted use of different techniques and technologies have enabled the safe and effective treatment of female patients treated for severe symptomatic aortic valve stenosis with similar results when compared with their male counterparts.

Tricuspid regurgitation (TR) poses a significant healthcare burden and is a major concern for patients who experience debilitating symptoms and face a poorer prognosis. Cardiologists are showing renewed interest in TR, as the previous belief that it was merely a bystander of left-sided heart disease has evolved. As a result, more transcatheter techniques addressing TR are emerging. Although a clear impact on mortality from these transcatheter tricuspid valve interventions (TTVI) has not yet been demonstrated, the improvement in symptoms and quality of life for patients is substantial, leading to increased use of these procedures in clinical practice. In this review, we focus on multimodality imaging as an essential tool for quantifying TR severity, assessing right ventricular (RV) function, understanding the underlying mechanisms, selecting the appropriate intervention, and ensuring thorough and accurate preprocedural planning to minimize complications.

We describe our technique for total aortic arch replacement with stenting of the descending thoracic aorta allowing normothermic cardiopulmonary bypass and avoiding hypothermic circulatory arrest.

Abstract Background and aim Aim of this study is to present the results of our aortic valve interventions program embedding surgical (SAVR) and trans–catheter treatment, both in the hands of cardiac surgeons. Methods Data of patients who had isolated aortic valve interventions during the period 2016–2022 were reviewed. SAVR was performed mainly through a minimally invasive approach . TAVI included either TF or TA access procedures, all performed in a cardiac surgery theatre with fluoroscopy equipment. Results During the study period, 1435 patients underwent isolated aortic valve intervention: 1022 surgical AVR (665 mini AVR, 357 FS) and 413 TAVI (333 TF and 80 TA). TAVI were introduced during 2018 and gained a wider application over the years with the progressive adoption of awake procedures and fully percutaneous access (Figure 1). The global volume of aortic valve procedures increased of 38% comparing the full–years 2021 with 2018 (295 vs 213 cases). Multivariable logistic regression showed that TAVI was significantly associated with increased age, female gender, a higher rate of comorbidities and lower LVEF. Overall in–hospital mortality was 0.6% – mini AVR 0.3%, FS 0.3%, TF TAVI 1% and TA TAVI 3%. Permanent neurologic injury was recorded in 0.7% of the patients. Permanent PM implantation was higher after TAVI (87/413 vs 32/1022 patients who had surgical AVR). Conclusions TAVI procedures can be safely performed by cardiac surgeons. The expertise in both surgical and trans–catheter treatment translated in the possibility of treating aortic valve disease in a higher volume of patients including older and comorbid patients with excellent early results.

OBJECTIVES: Current evidence on transcatheter aortic valve implantation (TAVI) has been generated exclusively by cardiology studies and no operative data from cardiac surgeons are available. Here, we describe the development of our TAVI programme and report the results of transfemoral (TF) TAVI done by cardiac surgeons on their own.METHODS: This study included all the TAVI procedures on native valve performed at Cardiac Surgery Unit, Ospedali Riuniti di Ancona, during the period October 2018 to July 2022. Relevant prospectively collected preoperative, intraprocedural and postoperative data were retrieved from the Institutional database.RESULTS: A total of 413 patients were included in the study. Mean patients' age was 82 years and among them 44% (180/413) were male. STS score was 3.1% (2.2-4.4). Eighty patients underwent transapical TAVI and 333 patients had a TF approach. We progressively moved from transapical TAVI towards TF procedures that are now routinely performed on conscious sedation and using a fully percutaneous approach. After TF TAVI, 30-day mortality rate was 1%, cerebral stroke occurred in 2% of the cases, permanent pacemaker implantation was necessary in 23% of the patients and in 6% of the cases there was a moderate/severe degree of aortic regurgitation. There was no association between operators performing TAVI and 30-day mortality.CONCLUSIONS: The acquisition of catheter-based skills and an adequate training allowed cardiac surgeons to perform on their own awake and fully percutaneous TF TAVI with similar results when compared with major randomized clinical trials and registries' experiences.

Abstract Background Minimally invasive cardiac surgery through right mini–thoracotomy access is nowadays an established approach for the treatment of mitral valve pathologies. Several thoracic incisions have been described and different techniques used for cardiopulmonary bypass, myocardial protection and valve exposure. Aim of this study is to review our early results with a minimally invasive approach characterized by a lateral right trans–axillary (TAx) approach and direct vision. Methods Prospectively collected data of patients who underwent mitral valve surgery between 2018 and 2021 were reviewed. Among them, 245 patients underwent minimally invasive mitral valve surgery through TAx access. A single incision at the fourth right intercostal space on the anterior axillary line, 3–to–5 cm in length (Fig 1), allowed a 90° direct view exposure of the mitral valve (Fig 2) and the subvalvular apparatus (Fig 3). A transthoracic clamp was invariably used to achieve the cardioplegic arrest. Results Mean age of the patients was 63 years and the mean EuroSCORE II was 1.6. Regurgitation was the prevalent mitral valve dysfunction (91%). Mitral valve repair was performed in 87% of the cases using several techniques including a combination of annuloplasty, leaflet resection and sliding, placement of neochordae and repair of the commissures. In patients with degenerative disease, the rate of valve repair was 92%. Tricuspid annuloplasty was associated in 10% of the cases. There was no in–hospital death; the rates of postoperative stroke and TIA were 0.4% and 1.2%, respectively. Median mechanical ventilation time was 3 [0–6] hours with 40% of the patients extubated in theatre at the end of the procedure. Median ICU stay was 24 [21–46] hours. Three patients had superficial complications of the thoracic wound and in 7 cases of the groin incision. After a median time of 7 [6–8] days, all the patients were successfully discharged from the hospital. The pre–discharge echocardiogram revealed none or trace residual mitral regurgitation in up to 96% of the patients who underwent mitral valve repair with a mean gradient across the valve of 3 [2–4] mmHg. Conclusions The TAx approach for minimally invasive mitral valve surgery is safe and allows a quick functional recovery. A superb direct view of the mitral apparatus and the ascending aorta, facilitates the exposure and the surgical repair of the valve with no need of any endoscopic nor an endoaortic balloon occlusion system support.

Abstract Objective Although, the use of protocols for “enhanced recovery after surgery” (ERAS) have been associated with improved results in different surgical disciplines, no data are available for EARS in cardiac surgery, thus far. In the late 2016 a mutlidisciplinary ERAS program to treat patients who require AVR was implemented in our institution. The aim of this study was to assess safety and 30 day outcomes in patients receiving ERAS management. Methods To improve multidisciplinary ERAS program, our mini–invasive approach (Fig. 1), that goes beyond a small incision, includes: (i) mini–surgical access (ministernotomy–minithoracotomy), to reduce the traumatic impact, postoperative pain and to increase patient’s satisfaction; (ii) minimal invasive extracorporeal circulation system, to improve end–organ protection and decrease systemic inflammatory response; (iii) ultra fast–track anaesthesia, to decrease the rate of postoperative complications and assure better and earlier recovery (Fig. 2). Results Between September 2016 and December 2021, 600 consecutive patients (mean age 72 years, Euroscore II 1,62%) underwent isolated mini–AVR in our institution. UFT anaesthesia was used in 195 patients (32.5%) and MiECC in 173 (28.8%). All patients received a timely rehabilitation therapy (3–6 hours after surgery) and an early family contact in ICU. At 30 days, the overall mortality and stroke rates were 0,3% (n = 2) and 0,5% (n = 3), respectively. Respiratory insufficiency occurred in 16 pts (2,5%). Median blood loss at 12 hours was 174,5 cc; blood transfusions were reduced to minimum intraoperatively and avoided in 66% of patients. Twenty three patients (3,8%) received definitive pacemaker implantation. The median ICU and in–hospital lengths of stay were 1 and 6 days, respectively. Conclusions Findings from our study confirms that mini–AVR yields excellent clinical outcomes with very low mortality and morbidity rates. The implementation of ERAS protocol in patients undergoing mini–AVR demonstrated to be safe and was associated with promising results. Thus, by reducing surgical injury and promoting faster recovery, ERAS management may further enhance minimally invasive interventions.

Median sternotomy incision has shown to be a safe and efficacious approach in patients who require thoracic aortic interventions and still represents the gold-standard access. Nevertheless, over the last decade, less invasive techniques have gained wider clinical application in cardiac surgery becoming the first-choice approach to treat heart valve diseases, in experienced centers. The popularization of less invasive techniques coupled with an increased patient demand for less invasive therapies has motivated aortic surgeons to apply minimally invasive approaches to more challenging procedures, such as aortic root replacement and arch repair. However, technical demands and the paucity of available clinical data have still limited the widespread adoption of minimally invasive thoracic aortic interventions. This review aimed to assess and comment on the surgical techniques and the current evidence on mini thoracic aortic surgery.

The first transapical transcatheter aortic valve implantation (TAVI) was successfully performed in 2005, and until a decade ago the transapical access (TAa) accounted for about one-half of all TAVI procedures. In addition to the risk of coronary occlusion, a coronary vessel can be directly damaged from the TAa. To reduce the risk of coronary injury, the pericardium must be opened as much as to locate the course of the left anterior descending artery. Iatrogenic mitral valve insufficiency by a guidewire crossing the aortic valve can be observed during TA-TAVI procedure. Compared to percutaneous TAVI, the TAa is associated with a higher risk of wound infection. The transaortic access is a valid option for TAVI in patients with hostile iliac-femoral vessels. This access has gained increased popularity in recent years.