transapical

Transapical refers to an approach to the heart that passes through the apex of the left ventricle. It is used in cardiovascular surgery and interventional cardiology to gain direct LV access for certain procedures, most notably transcatheter aortic valve replacement (TAVR/TAVI) when transfemoral access is not feasible. The term can also apply to other transapical procedures such as certain mitral interventions or temporary left ventricular assist device insertion, though these are less common.

Technique and applications: The patient is typically positioned for a left-sided chest approach, often a small left anterior mini-thernotomy to expose the LV apex. A purse-string suture is placed, and the apex is punctured to insert a short sheath or cannula into the left ventricle. Depending on the procedure, the valve or device is delivered across the aortic valve via the left ventricle, sometimes with cardiopulmonary bypass. After deployment, the apical entry is closed and hemostasis is achieved. The approach provides direct, stable access to the LV and avoids manipulation of the diseased aorta or peripheral vessels, which can be advantageous when other routes are unsuitable.

Risks and considerations: Transapical access involves thoracic surgery and myocardial injury at the apex, bleeding, and potential LV dysfunction. Other risks include apical pseudoaneurysm, pericardial effusion, arrhythmias, and the possible need for temporary or permanent pacing. Recovery can be longer than with some percutaneous approaches, and outcomes depend on patient anatomy and operator experience.

Current status: With advances in transfemoral technology and alternative routes, transapical access is used less frequently but remains an option when femoral or other percutaneous access is unsuitable or when specific devices and procedures require direct LV access.