Although numerous studies have reported low frequencies of SSIs in patients who have undergone cardiac surgery, the present study is the first to describe the infectious complications associated with TA-TAVI in detail as well as their management and outcome. SSIs remain one of the most important and dreaded surgical complications of all cardiac procedures. They can affect up to 2 to 5% of these patients and are the most frequent HAIs .
SSIs are a costly complication in all types of surgery and are associated with prolonged hospital stays, psychological distress, and increased mortality [13–16]. The commonly acknowledged risk factors are associated with the changing demographics of patients presenting with cardiovascular diseases and are linked to aging, obesity, diabetes, and chronic renal failure [17, 18].
The same principles used to cure deep sternal wound infection (DSWI) were used in the present study, with viable tissues i.e. pectoralis muscle and/or greater omentum being brought to the wound to achieve complete healing.
Following wound washout and debridement of nonviable tissues, resection of a segment of the adjacent anterior part of the 5th rib is recommend. Then and after partial mobilization of the inferior part of the pectoralis major, the LV apex is completely covered. In cases where further muscle tissue is needed, the pectoralis major can be completely mobilized from its insertions (including humeral) to optimize local treatments with minimal compromises in terms of postoperative function. Avoiding the use of the greater omentum may minimize abdominal complications such as herniation, although the omentum can now be easily mobilized with much less dissection using abdominal laparoscopic techniques.
Transposition of the greater omentum to reconstruct the chest wall through a subcutaneous tunnel has been described in the past to cure patients with complex skin ulceration following Halstead radical breast cancer surgery and chest wall irradiation  although Kiricuta  is mainly credited for the initial use of the greater omentum for chest wall reconstruction. The omentum has a known power of repair, is obviously very well vascularised and can regenerate tissue and cure infection .
Interestingly, we were able to cure all the infected patients despite the fact that foreign material was left behind i.e. apical pledgeted sutures. These patients have now all been followed for more than a year, and show no signs of recurring infections.
No severe sepsis, haemorrhaging, or false aneurisms were observed in these patients despite the fact that the left ventricular apex could be seen during surgical debridement and exposure. In our experience, the post-operative course of these patients was also uneventful, and the associated morbidity and mortality to date is lower than in patients afflicted with DSWI.
Pasic did report 3 patients that present late wound healing problems following TA-TAVI attributed to the use of glutaraldehyde and BioGlue . In their publication they did report that LV apical sutures and felt were all removed from the LV apex without bleeding complications.
Preventive measures taken before the TA-TAVI procedure should be the same as with any other cardiac interventions with extracorporeal circulation. It include a dental consultation, eradication of bacteriuria, and prophylactic treatment of nasal carriers of S. aureus with mupirocin and chlorhexidine bathing if the patient is not an emergency. Antibioprophylaxis should also be pursued aggressively in due time before surgery for these patients who often present with lifelong sequelae of diabetes.
During surgery, glycaemic control is mandatory and pericardial closure is recommend, as in any other standard open heart surgery.
To our knowledge, there are still very few descriptions in the literature of the results and infectious complications of TA-TAVI. Bleiziffer et al.  reported that two of 50 TA-TAVI patients (4%) had secondary wound healing problems that were managed with negative pressure wound therapy and delayed primary wound closure. We didn’t use negative wound pressure therapy for these patients with an open sinus leading to the apex of the left ventricle. Pasic  reported that two of 175 TA-TAVI patients (1.1%) had post-operative wound problems, one of whom being an MRSA carrier who eventually died from sepsis and another one who died from a groin infection following conversion to femoro-femoral cardiopulmonary bypass.
Minimally invasive valvular surgery and transcatheter aortic valvular replacement have recently been put forward as alternatives to standard open valvular replacement via sternotomy. These techniques are associated obviously with better cosmetic results, less pain and blood loss, better respiratory function and shorter hospital stays. They are challenging the way valvular surgery has been performed in the past and, as suggested by L. Cohn, and are opening the way to a paradigm shift in cardiac surgery .
The percentage (3.2%) of SSIs seen in this cohort of TA-TAVI patients was within the range of 2 to 5% observed in clean surgery. The infections mostly occurred during the learning curve of this procedure in our centre or during the first half of the cohort submitted to TA-TAVI.
The present study is the first to describe in detail the infectious complications associated with TA-TAVI as well as their management and outcome with pectoralis myocutaneous flaps and greater omentum transposition. Overall, the infections following TA-TAVI were mainly caused by Gram-positive species that are also seen in patients with DSWI. However, they caused less morbidity than infections following sternotomy. While the present study was underpowered and observational, a higher BMI was found to be a significant predictors of SSIs in this cohort of patients who underwent this minimally invasive valvular procedure.