Surgeon Q&A: “What Determines the Transfemoral or Transapical Approach for TAVR?” Asks Denise
Given the recent FDA approval of transcateher aortic valve replacement devices (TAVR), I continue to receive interesting questions from our patient community. For example, Denise recently wrote to me, “Hi Adam – My mom is 84 years old and diagnosed with severe aortic stenosis. We’re researching the possibility of using the catheter valve to help her. I’ve read that the valve can be inserted through the groin or through the heart. What determines the way in which this valve is implanted? Is one better than the other? Thanks, Denise.”
Denise raises a great question. That said, I wanted to provide Denise a great answer. For that reason, I contacted Dr. Mathew Williams, the Co-Director of the Columbia Heart Valve Center which is part of NewYork-Presbyterian Hospital at Columbia University Medical Center. So you know, Dr. Williams is uniquely qualified to address Denise’s question considering that he trained in both cardiac surgery and interventional catheter-based techniques.
About the Transfemoral and Transapical Approaches for TAVR
In his response to Denise, Dr. Williams made several helpful distinctions about TAVR and the transfemoral and transapical approaches. He also referenced the transaortic approach which I was unfamiliar with.
Hello Denise, thank you for your question. Transcatheter Aortic Valve Replacement (TAVR) is a viable treatment option for patients who are diagnosed with severe aortic stenosis and are high risk for open heart surgery due to their age or other medical conditions making them poor candidates for surgery. Approximately 80 percent of our patients at the Columbia Heart Valve Center have the procedure done through the femoral artery, or a transfemoral approach. A catheter is placed in the groin area and a new valve enclosed in a metal stent is threaded to the diseased aortic valve using the patient’s vessels as a pathway. The prosthetic valve is carefully positioned, expanded, and anchored inside the diseased valve. The transapical approach is designed for patients who have small or diseased vessels preventing access from the groin to the aortic valve. A small incision is made just under the left chest and the valve is advanced through the ribs to the apex, or tip of the heart. A third approach is currently in clinical trials, called the transaortic approach. The transaortic approach involves direct access to the aorta through a small incision on the top portion of the breast bone. This is also designed for patients who have inadequate femoral arteries. Your mother will have several diagnostic tests before her procedure to determine which access route is best for her.
Dr. Mathew Williams – Co-Director of the Columbia Heart Valve Center
Dr. Williams then addressed Columbia’s preferential technique for TAVR procedures:
Our preference is to use the transfemoral approach when possible because the recovery time in the hospital is shorter. Patients who have a procedure done via the transfemoral approach on average recover in the hospital for three-five days barring any complications. Those who have the transaortic or the transapical approach can expect to remain in the hospital between five-seven days to ensure the incision heals properly.
Finally, Dr. Williams addressed Denise’s patient advocacy efforts and the need for action specific to aortic stenosis:
The great news is that you are exploring treatment options for your mother. Aortic stenosis is a very aggressive disease and the two year survival rate for symptomatic aortic stenosis is less than 50% if left untreated. Whether your mother has surgery which is also an excellent therapy with very positive outcomes, or TAVR, we encourage your mother to seek treatment earlier rather than later for the best results. Good luck and I hope your mother’s treatment is a success. — Mathew R. Williams, MD
I hope this helped you learn more about the transfemoral and transapical approaches for TAVR. Thanks to Denise for sending me this question and a special thanks to Dr. Mathew Williams for sharing his clinical experience and research with our patient community!
Keep on tickin!
Adam Pick is a patient, author of The Patient's Guide To Heart Valve Surgery and the founder of HeartValveSurgery.com.