Transapical TAVI in Left Ventricular Apical Aneurysm

Transcatheter aortic valve implantation (TAVI) was the preferred intervention for patients with severe aortic stenosis at high surgical risk and recently included intermediate and even low surgical risk patients. The transfemoral (TF) route is the standard approach, with alternative access reserved for patients with challenging peripheral artery disease. The transapical (TA) approach is rarely performed, especially in patients with left ventricular (LV) apical aneurysm due to risk of myocardial rupture and bleeding secondary to fibrosed myocardial tissue. We are presenting the first reported case, to our knowledge, of a TA TAVI performed from an LV apical aneurysm despite fibrosed myocardium after failed TF access with severe bicuspid aortic stenosis, advanced ischemic cardiomyopathy, peripheral vascular disease, and chronic obstructive pulmonary disease (COPD). A 29 mm Edwards Sapien S3 Ultra valve was successfully implanted with residual trivial paravalvular regurgitation and stable postoperative recovery. This case highlights the feasibility of TA TAVI in the presence of LV apical aneurysm when no other vascular access route is possible, contrary to the perceived view of the LV aneurysm being thin and friable, which should not preclude a case being done with TA access.