While transcatheter aortic valve implantation (TAVI) technologies have recently advanced and clinical trials have found the benefits of transapical and transfemoral techniques, the transfemoral should trump the transapical approach, according to a presentation by Jeffrey W. Moses, MD, at the 22nd annual Transcatheter Cardiovascular Therapeutics (TCT) conference Sept. 22 in Washington D.C.
“Why would we even conceive the transapical approach?” asked Moses. “Initially when we were talking about the replacement of aortic valves, we really weren’t conceiving a surgical procedure,” asked Moses, who is from the N.Y. Presbyterian Hospital and Columbia University Medical Center in New York City.
However, he said that the transapical approach aids in avoiding complex iliofemoral disease that can lead to dissections, occlusions and perforations; facilitates valve crossing; enhances the control of placement; and can help avoid hitting complex anatomy and hazards that can lead to dissection or stroke.
Results of previous trials have shown that the transfemoral approach may be superior, but patients within transapical groups often have higher incidences of renal failure and peripheral vascular disease. However, while Moses said that early pooled studies showed better survival results for the transfemoral approach, data from the SOURCE registry and the Vancouver TAVI experience proved that transapical results are getting better.
During the Vancouver TAVI experience, researchers of the Quebec Heart and Lung Institute in Quebec City, compared transapical and transfemoral valve delivery approaches and evaluated survival rates at one year. Survival rates were reported to be comparable for the two groups at both one year and two years. At one year, survival rates were 75 percent for the transfemoral approach and 78 percent for the transapical and at two years these rates were 65 percent and 64 percent, respectively.
“While I’m not necessarily saying that the transfemoral approach is better, there is no evidence that the transpical approach surpasses the transfemoral's superior 30-day and one-year survival rates,” he noted. "There is never a series where you see a superior result with the transapical approach."
Results are improving, however, for both transapical and transfemoral approaches, which Moses attributed to operator experience, better patient selection and awareness and anticipation of complications.
In terms of stroke benefit, Moses said that while “it’s great in theory," there is no benefit to using the transapical approach in subsets of patients with stroke. Additionally, he said that arrhythmia and pacemaker implantation rates are low with the Sapien transcatheter valve (Edwards Lifesciences) and there is no superiority when using the transapical approach.
Moses offered that while utilizing the CoreValve (Medtronic) used to be deemed a very complex procedure, today it can be implanted without the need for hemodynamic support and with conscious sedation.
“Most of the rationale for choosing either transapical or transfemoral approaches have dissipated as these techniques and the associated technologies have advanced and we have more robust data sets to test certain hypotheses.
“But, it seems obvious that if you can choose the transfemoral approach, do transfemoral,” Moses concluded.