Transfemoral or transapical aortic valve implantation?


Cardiovascular News International met Michael Mack (Medical City Dallas Hospital, Dallas, USA) and Thomas Walther (Bad Nauheim, Germany) at the opening day of the 24th European Association for Cardio-Thoracic Surgery EACTS annual meeting in Geneva, Switzerland.
Mack and Walther stated that the percentage of transfemoral aortic valve implantations against the transapical ones in the United States is significantly higher than in Europe.    

Q: How would you explain the higher transfemoral aortic replacement procedure rate in the United States compared to Europe?

Michael Mack: In Europe physicians have free access to use whichever technology they want, whereas in the United States transcatheter heart valve implantation is still a technology under a trial basis – therefore physicians have to go with the design of the trial. And the trial mandates that physicians have to attempt the transfemoral approach first, and only if this is not possible then they can use the transapical approach.


Thomas Walther: In Europe there is a more robust trend for the transapical approach within TAVI and I think that the 50–50% split should be the golden standard.


Q: Why do you think a number of surgeons both in Europe and in the United States seem to be more open to the transfemoral technique than to the transapical one?

TW: TAVI is a new technique and we still need to learn, but wider skills require time. Cardiologists have learnt those skills over the years, so they are obviously ahead of surgeons in this field.


MM: I think that one of the things that may explain why the transapical technique has been around the United States fluctuating since its first appearance, is because even experienced surgeons have some kind of trepidation around the transcatheter aortic implantation. Surgeons that do a lot of ventricular assist devices and deal with transcatheter aortic implantations all the time are very comfortable with it. Surgeons that do not do transcatheter implantation at the heart are very timid. And when you are timid with the stitches that you put in, that is when it leads to problems that can give you more problems, which make you even more timid. So there is a learning curve that surgeons have to get over, because the transapical implant at the heart is a common place that most surgeons are not used to operate on at the moment.