Antegrade transseptal transcatheter aortic valve replacement: Back to the future?

Abstract

Antegrade transseptal approach was utilized in the first human case of transcatheter aortic valve replacement (TAVR) and in the early phase of TAVR. Various challenges with the antegrade transseptal approach including procedural complexity, need for atrial septal crossing, and potential for injury to the mitral valve apparatus led it to being supplanted by other approaches. These challenges have now largely been mitigated as structural interventionalists routinely perform left atrial procedures. We report a case of antegrade transseptal TAVR using a large bore sheath placed in the mid left ventricle across the mitral orifice to protect the mitral valve apparatus and facilitate valve deployment. An 84‐year‐old man with heart failure symptoms was seen for severe aortic stenosis. The severity of peripheral arterial disease precluded femoral, axillary, carotid, or transcaval routes. After transseptal puncture and creation of an arteriovenous rail, a long 26‐Fr sheath was advanced from the right femoral vein transseptally over the arteriovenous rail, past the mitral valve inflow to the mid left ventricular cavity. The sheath provided a stable platform with stable intraprocedure hemodynamics. Balloon valvuloplasty was performed in an antegrade manner, after which a 29‐mm SAPIEN S3 prosthesis was advanced into the aortic valve position and deployed under rapid pacing. We observed no injury to the mitral leaflets or subvalvular apparatus after the procedure. The antegrade transseptal approach should be revisited as an option for patients at high surgical risk with no other suitable access site. The use of a large bore sheath facilitates this approach.

Anterograde Crossing of a Bicuspid Aortic Valve Through Transseptal Access to Facilitate Transcatheter Aortic Valve Implantation

“…Antegrade transseptal approach with antegrade deployment of the prosthesis has been utilized in the early phase of TAVI but is now reserved for cases where there are no other suitable access sites. [ 6 ] In our case, we already had large bore femoral access, and we were therefore able to snare the guidewire, pass a guide catheter into the left ventricle retrogradely and exchange to a Safari wire, allowing standard retrograde implantation of the prosthesis.…”

Alternative Access for TAVR: Choosing the Right Pathway

“…for atrial septal defect closure devices has been developed, but has largely been replaced by other alternative options [11,12]. However, due to the risks involved in antegrade septal crossing, attention was mainly focused on the refinement of other approaches, particularly the transfemoral approach [13]. As TAVR became more common, the need for additional alternative accesses apart from the transfemoral approach became evident due to challenges with severe PAD due to atherosclerosis and calcifications, tortuosity of the iliofemoral system, and the presence of thoracic or abdominal aortic aneurysms.…”

“…This approach is still occasionally used as a bail-out strategy for alternative access when all other approaches have been explored, particularly as newer technology for atrial septal defect closure devices has been developed, but has largely been replaced by other alternative options [ 11 , 12 ]. However, due to the risks involved in antegrade septal crossing, attention was mainly focused on the refinement of other approaches, particularly the transfemoral approach [ 13 ].…”

Commentary: The value of access agility in the world of transcatheter aortic valve replacement

“…Transaortic or transapical access in addition to transcaval and transeptal modalities are to be considered when there are no arterial options. 3 The authors as well as surgeons across the country who have contributed to the progress of TAVR should be congratulated on these advancements. TC access has evolved into a safe and feasible approach when transfemoral access is not possible and many patients will benefit.…”