Transapical Aortic Valve Implantation: A Systematic Review

Introduction: Transcatheter aortic valve implantation (TAVI) through a transapical approach (TAAVI) for severe aortic stenosis is the alternative procedure in patients with peripheral artery disease and unfeasible access due to excessive atherosclerotic disease of the iliofemoral vessels and aorta. The present systematic review aimed to assess the safety, success rate, clinical outcomes, haemodynamic outcomes, and survival benefits of TAAVI. Methods: Electronic searches were performed in six databases from January 2000 to February 2012. The primary end points included feasibility and safety. Other end points included echocardiographic findings, functional class improvement, and survival. Electronic searches were performed in six databases from January 2000 to February 2012. The primary end points included feasibility and safety. Other end points included echocardiographic findings, functional class improvement, and survival. Results: After applying the inclusion and exclusion criteria, 48 out of 154 shortlisted potentially relevant articles were selected for assessment. Of these, 26 studies from 24 centres including a total number of 2807 patients were included for appraisal and data extraction. The current evidence on TAAVI for aortic stenosis is limited to observational studies. Successful TAAVI implantation occurred in >90% of patients. On average, the procedure took between 64 and 154 min to complete. The incidence of major adverse events included 30-day mortality (4.7–20.8%); cerebrovascular accident (0–16.3%); major tachyarrhythmia (0–48.8%); bradyarrhythmia requiring permanent pacemaker insertion (0–18.7%); cardiac tamponade (0–11%); major bleeding (1– 17%); myocardial infarction (0–6%); aortic dissection/rupture (0–5%); moderate to severe paravalvular leak (0.7–24%); cardiopulmonary bypass support (0–15%); conversion to surgery (0–9.5%); and valve-in-valve implantation (0.6– 8%). Mean aortic valve area improved from 0.4 to 0.7 cm before TAAVI to 1.4–2.1 cm after TAAVI. The peak pressure gradient across the aortic valve decreased from>70 mmHg to <20 mmHg after TAAVI. One-year survival ranged from 49.3% to 82% and the three-year survival was 58% in two series. Discussion: TAAVI appears to be feasible with a reasonable safety and efficacy portfolio. Randomised controlled trials are required to compare transapical vs. transfemoral TAVI when both techniques are equally feasible.