*2.2.2 Myval BEV*

Myval's design is created with hexagons. Its special design has large open cells toward the aortic end, while it has closed cells toward ventricular end to maintain higher radial force (**Figure 6**). Unlike other valves, Myval has a large number of sizes, such as conventional (20, 23, 26 and 29 mm), medium (21.5, 24.5 and 27.5 mm) and extra large (30.5 and 32 mm). Myval THV of size 32 mm got CDSCO (Central Drugs Standard Control Organization, India) approval and 30.5 mm is pending CDSCO approval. Medium sizes are for avoiding a serious complication of BEV, annular rupture. The platform uses 14 F delivery system [23].

#### *2.2.3 Inovare BEV*

Inovare BEV consists of tri-leaflet bovine pericardial valves mounted in a cobalt-chromium stent frame and is available in four sizes of 20, 22, 24 and 26 mm (**Figure 7**). The valve is implanted using the transapical and transaortic approach [24].

*Transcatheter Aortic Valve Replacement Technique and Current Approaches DOI: http://dx.doi.org/10.5772/intechopen.111904*

**Figure 6.** *Myval design.*

**Figure 7.** *Inovare design.*

*2.2.4 Colibri BEV*

There are limited clinical data and Colbri BEV is a prefabricated TAVR system. The valve has a unique folding technique and is made of three independent porcine pericardium pieces. The first implantation was performed in November 2012 [24].


#### **Table 3.**

*General recommendations for choosing a proper valve.*

**Table 3** summarizes general recommendations for choosing a proper valve; however, the most important recommendation is to use the platform that the operator is experienced to handle.

### **3. Accesses in TAVR procedure**

Over the past 20 years, TAVR has become an alternative treatment for severe aortic stenosis. For this treatment, operators need a suitable access. According to the current guidelines, femoral approach is the first choice [25, 26].

#### **3.1 Transfemoral approach**

Transfemoral access is the first choice in TAVR procedures. This is because operators are experienced in handling femoral access and possible complications can be managed easily. Despite technical improvement in vascular sheath diameters, 10–20% of all patients are not suitable for undergoing transfemoral access due to advanced peripheral arterial disease [27]. So for these unsuitable patients, alternative access sites have been searched. TAVR can be performed alternatively via transapical, transaortic, transsubclavian/transaxillary, transcarotid, transcaval and suprasternal approaches. But before searching for an alternative site, it is very important to evaluate iliofemoral anatomy. First of all starting from the carotid arteries, subclavian-axillary arteries, aorta and iliofemoral arteries are evaluated with multidetector computed tomography (CT). Minimal lumen diameter is determined. It is very important to evaluate iliofemoral arteries and aortic tortuosity and calcification. Circumferential calcifications, calcification protruding into the vessel lumen and anteriorly located calcifications mostly interfere with femoral access. If problems can be solved, femoral access should be used. Balloon angioplasty and lithotripsy, e.g., can be used to modify calcification and/or stenosis. Such Lunderquist and Back-up Mayer guidewires can be used to handle iliofemoral and aorta tortuosity. The plaques in aortic arch, porcelain aorta and thoracoabdominal aneurysms should be evaluated. After all if femoral access is not suitable, alternative sites should be detected. The most important criterion is operator's experience.
