Cardiac surgeons operate through small incisions in the neverless chest, eliminating the need for a sternotomy, stopping the heart, or requiring a heart-lung machine to be used. Decreased trauma to tissue and muscle with smaller incisions typically results in less pain. Avoiding the bypass machine reduces the risks for neurological complications and stroke. In general, minimally invasive cardiac surgery, in comparison to traditional procedures, offers many benefits including reduction of the chance for postsurgical complications and leads to shorter hospital stay with a faster return to normal activities. Aortic valve replacement is such a cardiac procedure that can be performed with minimally invasive techniques. In the last decade, transcatheter aortic valve replacement (TAVR) has been studied for treating the patients of high surgical risk.

The bioprosthetic valves are delivered through catheters transfemorally [8�C13] or transapically [14�C18] and are implanted within the diseased aortic valve. In current clinical practice, the transfemoral approach is the first choice, while the transapical method is only chosen for patients who have poor vascular access [19]. However, the transapical aortic valve approach may be more applicable to a wider range of patients because of the lack of physical anatomic limitations. Antegrade access avoids possible complication with retrograde access, which is caused by inability to cross a stenotic valve. Larger sheath diameters used in the transapical access lead to less need for crimping of the valves, which may be translated into better prosthesis longevity [20, 21].

Early, midterm, clinical, and echocardiographic outcomes indicate that both approaches are comparable [22], despite a significantly higher risk profile in the cohort treated with the transapical approach [23]. Typically, the imaging employed for TAVR is primarily high-resolution fluoroscopy and adjunctive 2-dimensional M-mode transesophageal echocardiography. The problems with fluoroscopy guidance include device embolization, coronary obstruction, low or high placement, misalignment, landmark loss (after ballooning the valve the calcium pattern used by fluoroscopy to identify the leaflets/annulus is changed), perivalvular leaks, need for rapid ventricular pacing, radiation exposure, and intravenous contrast toxicities.

All of these are imaging related and may be improved with better imaging; hence our desire is to pursue magnetic resonance imaging guidance. MRI provides excellent visualization particularly in its ability to provide high-resolution images of blood-filled structures without additional GSK-3 risk of radiation or contrast reaction. Vascular as well as soft tissue visualization can easily be performed simultaneously. MRI also provides the ability to assess ventricular and valvular function and myocardial perfusion.