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Optimal pain management after aortic valve implantation: an opportunity to improve outcomes after transapical access in the future?
  1. Rafal Dworakowski,
  2. Olaf Wendler
  1. King's College Hospital/King's Health Partners, Department of Cardiology and Cardiothoracic Surgery, London, UK
  1. Correspondence to Professor Olaf Wendler, King's College Hospital/King's Health Partners, Denmark Hill, London SE5 9RS, UK; olaf.wendler{at}nhs.net

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Ten years after transcatheter aortic valve implantation (TAVI) was pioneered by Alain Cribier in 2002, it has been accepted as an alternative treatment for aortic stenosis. The PARTNER–US trial, in which the Edwards Sapien (Edwards Lifesciences, Irvine, California, USA) transcatheter heart valve (THV) was used and the mortality risk for surgical aortic valve replacement (AVR) was jointly estimated by the heart team (cardiologist and cardiac surgeon), is the first prospective randomised trial on TAVI. Results demonstrate superiority of TAVI compared with medical treatment, in patients with an estimated AVR mortality of 50% or greater (cohort B).1 Cohort A results confirm that TAVI also compares to AVR in patients seen to be at high risk of open heart surgery (AVR mortality estimated ≥15% to <50%).2

So far the vast majority of TAVI has been performed through transfemoral and transapical access. Until recently, the Edwards Sapien was the only THV with CE mark accreditation for transapical TAVI, and is still the only device that has been approved by the US Food and Drug Administration. Alternative access routes through the subclavian artery and ascending aorta are currently being explored and offer additional treatment opportunities.

The extensive European TAVI experience using the Edwards Sapien THV has been reported previously and the SOURCE Registry, the largest European TAVI registry, demonstrated favourable outcomes for transfemoral and transapical access.3 ,4 In contrast to the transfemoral approach, transapical TAVI is not restricted by size and quality of the iliofemoral arteries and therefore inclusion criteria for the two access routes are different. This results in a higher risk profile for the transapical group and may explain the slightly higher 30-day (10.3% vs 6.3%) and 1-year mortality (27.9% vs 18.9%) found in SOURCE for transapical patients.3 ,4 This view …

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    BMJ Publishing Group Ltd and British Cardiovascular Society