1. Techniques in Transapical AVR Vinod H. Thourani, MD Professor of Surgery and Medicine Chief of Cardiothoracic Surgery, Emory Hospital Midtown Co-Director: Structural Heart and Valve Center Emory University School of Medicine AATS April 2015

2. Disclosures Edwards Lifesciences –Emory Co-PI: PARTNER 1 and 2 –National Co-PI: PARTNER 2 (SAPIEN 3 Trial) with Dr. Susheel Kodali St. Jude Medical –Emory PI Portico Trial, Structural Heart Advisory board Boston Scientific –Emory PI: REPRISE Trial –Advisory Board, Executive Comm (Lotus Valve Trial) Medtronic –Emory PI: SURTAVI Trial Jenavalve –National Co-PI with Dr. Martin Leon Abbott Medical –Emory Co-PI: Coapt Trial Apica Cardiovascular –IP, co-founder

3. In 2015

4. Transapical and Transaortic Transcatheter Aortic Valve Replacement in the United States Thourani, Jensen, Babaliaros, Suri, Vemulapalli, Dai, Brennan, Rumsfeld, Edwards, Tuzcu, Svensson, Szeto, Herrmann, Kirtane, Kodali, Cohen, Lerakis, Devireddy, Sarin, Carroll, Holmes, Grover, Williams, Maniar, Shahian, and Mack On behalf of the ACC/STS TVT Database Team 51 st Annual Meeting of the STS January 26, 2015

5. Access Site Source: STS/ACC TVT Registry (7/1/2012-6/30/2014 )

6. MortalityOverall N=4,953 TA TAVR (N=4,085) TAo TAVR (N=868) P value 30 Day (%)9.18.810.30.006 6 Month (%)20.319.722.8 1 Year (%)26.325.630.3

7. Single-lumen intubation Single-lumen intubation TEE TEE Foley catheter, translucent defib pads Foley catheter, translucent defib pads Small roll parallel to spine behind L scapula Small roll parallel to spine behind L scapula 5-6 cm 5 th - 6 th intercostal anterolateral thoracotomy 5-6 cm 5 th - 6 th intercostal anterolateral thoracotomy 6F access to femoral art 6F access to femoral art Pacing wire via femoral vein Pacing wire via femoral vein Lidocaine 100mg Lidocaine 100mg Heparin > ACT 250 seconds Heparin > ACT 250 seconds Transapical Technique

14. Transapical AVR is: Transapical AVR is: Direct and antegrade Direct and antegrade Potential for minimal embolic neurologic events Potential for minimal embolic neurologic events No limitation to sheath diameter No limitation to sheath diameter Expeditious and less time consuming Expeditious and less time consuming Minimizing radiation Minimizing radiation Minimizing contrast to the elderly patient Minimizing contrast to the elderly patient Applicable in all patients Applicable in all patients Summary

15. Need for TA Access in the Future The TMVR is Coming

16. It allows minimal morbidity and mortality when careful and thoughtful surgical technique is followed It allows minimal morbidity and mortality when careful and thoughtful surgical technique is followed Success can only be achieved with a collaborative and dedicated team Success can only be achieved with a collaborative and dedicated team Conclusions

17. Thank You Vinod H. Thourani, MD vthoura@emory.edu