TAVI: transapical--what else?

Transcatheter aortic valve implantation is a relatively new technique to treat elderly and high-risk patients with aortic stenosis using a retrograde transfemoral, transsubclavian, transaortic or an antegrade transapical approach. TAVI procedures can be divided into two parts: the access to the cardiovascular system, and valve positioning and implantation. Regarding access, an antegrade transapical approach is intuitively easy to perform and thus the logical approach. At present a lateral mini-thoracotomy is required, but for the future percutaneous access and closure systems will be available. The transapical approach per se offers plenty of advantages as it is easy to perform, is very close to the target, antegrade, allows for easy guidewire insertion together with simple antegrade valve placement and a very controlled implantation. Despite this, in clinical reality many sites use a "transfemoral first" approach to TAVI, which is based merely on the belief that this is supposed to be less invasive; however, this belief is not substantiated by evidence-based data. In effect, the transapical approach offers the lowest access-related complication rates, and should therefore be the access of choice for many patients.