Transapical transcatheter aortic valve replacement provides an effective alternative for patients with severe aortic stenosis and complex aortoiliac disease, with experienced centers achieving short-term mortality rates comparable to transfemoral approaches.
This review evaluates the role, indications, outcomes, and future potential of the transapical approach for transcatheter aortic valve replacement.
Historically, the treatment of aortic stenosis (AS) has been open aortic valve replacement (AVR) utilizing cardiopulmonary bypass (SAVR) via either a median sternotomy or minimally invasive techniques. These techniques have produced durable results with low morbidity and acceptable long-term survival (1). However, at least 30% of patients with severe symptomatic aortic stenosis do not undergo surgical replacement of the aortic valve, due to advanced age, left ventricular dysfunction, or the presence of multiple coexisting conditions (2). In an effort to provide a practical alternative and mitigate risk in this elderly, frail population, transcatheter strategies of aortic valve replacement have been developed. In 2002, Cribier performed the first transcatheter aortic valve replacement (TAVR) through a transvenous, transeptal technique (3). In the subsequent decade, TAVR has evolved and is currently being performed primarily via a retrograde transfemoral (TF), a direct left ventricular transapical (TA), or direct transaortic (TAo) techniques. Most programs have established a femoral-first approach to TAVR, reserving the TA approach for patients with severe, lesion-limiting aortoilliac disease. Transaortic AVR has recently gained traction with more sites utilizing this procedure with either an upper partial mini-median sternotomy or right lateral thoracotomy. However, with the advent of the SAPIEN XT and the Esheath technology (Edwards Lifescience, Irvine, CA), the percentage of patients able to receive TF TAVR will increase. This article will evaluate the role of the transapical approach by evaluating the indications (both before and after the development of the SAPIENXT valve) for and outcomes following TA-TAVR. It will also evaluate the established and theoretical advantages of a TA approach, as well as the unique aspects of the TA access that could facilitate new approaches to valvular therapies even beyond the aortic valve.
Shults et al. (Sun,) conducted a review in Severe symptomatic aortic stenosis. Transapical transcatheter aortic valve replacement (TA-TAVR) vs. Surgical aortic valve replacement (SAVR) or Transfemoral TAVR was evaluated. Transapical transcatheter aortic valve replacement provides an effective alternative for patients with severe aortic stenosis and complex aortoiliac disease, with experienced centers achieving short-term mortality rates comparable to transfemoral approaches.
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