Transcathater aortic valve implantation in transapical access.

To the Editor,

We congratulate Doğan et al. (1) on their successful transcathater aortic valve implantation (TAVI) entitled “Transcatheter aortic valve implantation through extra-anatomic iliac graft in a patient with unsuitable iliofemoral and subclavian anatomy.” published in Anatol J Cardiol 2016;16:813-4. The authors report that they conducted the procedure through the synthetic graft, which they anastomosed to the left common iliac artery of the patient as the femoral and subclavian access routes were diseased. They explained why they did not conduct the procedure transapically by referring to the studies of Fröhlich et al. (2). It is reported in this study too that transapical TAVI has higher mortality rates than other methods. However, we are of the opinion that for this patient, the TAVI procedure should be conducted transapically rather than through a synthetic graft in spite of the opposite hypothesis of Doğan et al. (1). There is no consensus on the hypothesis that a transapical attempt is more reliable than a transfemoral attempt. A lot of studies indicate that transapical TAVI is at least as reliable as other access routes (3–5). In one of these studies, it is even stated that the transapical approach is better than the transfemoral approach in terms of postoperative paravalvuler leakage (4). In another study, the transapical approach has been found to offer a better manoeuvre ability than the transfemoral approach during prosthesis placement (5).

We are of the opinion that another reason why Doğan et al. (1) preferred the transapical route in this patient can be that the patient had a previous cardiac operation. However, the transapical attempt could have been conducted with a minimum invasive thoracotomy in this case as well. The patient had a general anesthesia while an iliac graft was being transposed. Moreover, even though the authors do not mention it completely, it appears that the patient’s TAVI procedure was conducted in two different sessions, with at least one of them being under anesthesia, because picture 2 shared by the authors indicates a healed incision scar on the patient. This means that the patient underwent anesthesia stress twice, whereas this procedure could have been conducted in a single session in a transapical attempt.

However, we are of the opinion that the fact that an access graft for TAVI was ligatured naturally after the operation and left in the body was another handicap for this patient. This is because it is probable that a rudimentary graft in the abdomen could be the cause of infection. We think and believe for all these reasons that even if the conventional transfemoral attempt could not be conducted, the transapical route should have been preferred instead of an iliac arterial graft.