Choosing the right access site for TAVI—doing things right or doing the right things

The heart team is the interdisciplinary platform of the present and of the future and together with our cardiology colleagues we have thrived by sharing knowledge and by developing joint strategies, thereby taking the treatment of structural heart valve disease to the next level [1]. However, there is daily routine that sometimes distracts and where decisions are sometimes taken without the necessary attention to the very detail, which can at the end make the difference regarding success or failure of what we recommend to our patients. Let us share a snapshot from a typical heart team meeting where many of us will see themselves mirrored. The clinical case is presented starting with the underlying valvular heart disease diagnosis, followed by other diagnoses and general frame conditions, EuroSCORE II and Society of Thoracic Surgeons (STS) scores are mentioned, then the transthoracic echocardiography is shared, eventually a transoesophageal echocardiography in case of remaining issues which cannot be ruled out or verified by transthoracic echocardiography, the left heart catheterization is presented and then the computed tomography angiography (CTA) from tip to toe is shown for evaluation of both suitability for transcatheter aortic valve replacement (TAVI) and suitability for femoral access. In case the decision goes for TAVI, this is the point where everybody’s visual and cognitive attention goes to the iliac axis and everything else vanishes. The access site bazar is now open and usually transfemoral diameter trade-offs are accepted up to the point where a series of lucky punches turns into a series of less successful punches needing complex iliac and femoral repair, which usually then shifts the notion to a more liberal choice of alternative access sites like the apex of the left ventricle, the left subclavian artery or the left common carotid artery, which all show excellent results if handled appropriately [2–4]. In other words, the long way between access and accomplishment of therapy from the iliac axis to the aortic root is hardly ever analysed in detail. This is where the current study elegantly raises attention [5]. The privilege of surgery is the knowledge upon tissue texture and quality via preoperative imaging as we are the ones who do have the tissue in our hands on a daily basis and can anticipate what to expect. We already learned our lessons regarding obliterative load and the remaining risk during wire manipulation in thoracic endovascular aortic repair involving the aortic arch [6] as well as in downstream aortic segments [7]. After all, the underlying disease process shall guide us what to do and what to refrain from and not the technical feasibility of a method or an access site. So, despite the given feasibility with regard to diameters, other factors are decisive for which access site to choose and shaggy aortas are one of them. Clinically apparent stroke after TAVI has become a rare event and if it happens, valve morphology, its calcific load or extensive manipulation are the known causative suspects in the early phase after the procedure. A more differentiated view upon the entire aorta in particular at the level of the aortic arch has helped to reduce the remaining risk of stroke in the treatment of thoracic aortic pathology involving the aortic arch to a minimum and the findings of the current study elegantly show us that this can also be achieved in TAVI. This is also true for embolic complications in downstream aortic segments hosting major offsprings such as the visceral and renal arteries. A more liberal use of the left ventricular apex avoids retrograde delivery and, in case of adequate aortic arch morphology and suitable diameters of both angulations and offsprings of the left subclavian artery or left common carotid artery, the supra-aortic branches are also an excellent access site choice for many patients. Here, the circle closes as adequate experience with these access sites for TAVI is key to a successful programme and these access sites have to be used in appropriate manner and frequency. A well-grounded interdisciplinary platform where we meet as partners at eye level will help to do the right things in the right patients now and in the future. Conflict of interest: none declared.