Key result
Trans-aortic TAVR was associated with higher in-hospital mortality (15%) compared to trans-apical (2%), trans-subclavian (0%), and trans-carotid (2%) access (P=0.014).
Why the study?
Do different non-transfemoral access techniques for TAVR yield different clinical outcomes and mortality rates in older adults with severe aortic stenosis?
Observational (n=172)
Yes
Do different non-transfemoral access techniques for TAVR yield different clinical outcomes and mortality rates in older adults with severe aortic stenosis?
p-value: p=0.014
While trans-aortic TAVR may be associated with higher in-hospital mortality, all non-transfemoral access techniques offer similar one-year mortality and clinical outcomes, with trans-carotid access being a safe and feasible alternative.
Higher in-hospital mortality with trans-aortic access warrants caution; leaves open optimal non-femoral TAVR strategy pending randomized data.
BACKGROUND: We examined the outcomes of older adults undergoing nontrans-femoral (non-TF) transcatheter aortic valve replacement (TAVR) procedures including trans-apical (TA), trans-aortic (TAo), trans-subclavian (TSub), and trans-carotid (TCa) techniques. METHODS AND RESULTS: This is an observational study of all consecutive older patients who underwent non-TF TAVR for symptomatic severe AS with Edwards Sapien (ES), Medtronic CoreValve, ES3 or Lotus Valve at three centers in France and the United States from 04/2008 to 02/2017. Baseline characteristics and clinical outcomes were defined according to VARC-2 criteria. Of 857 patients who received TAVR, 172 (20%) had an alternative access procedure. Of these, 45 (26%) were TA, 67 (39%) TAo, 17 (10%) TSub, and 43 (25%) TCa procedures. The preference for non-TF access site was different between the two countries (US: TA 39%, TAo 52%, TSub 9%; TCa 0% vs. France: TA 9%, TAo 23%, TSub 11%, and TCa 57%, P-value < .001). Most patients who underwent TAo TAVR were older women (median age: TA 82, TAo 84, TSub 81, TCa 81, P-value = 0.043; female gender: TA 32 (27%), TAo 30 (55%), TSub 10 (41%), TCa 27 (37%), P-value = .021). The predicted Society of Thoracic Surgery risk of mortality was similar among groups (TA 7%, TAo 7%, TSub 6%, TCa 7%, P-value= .738). No differences were observed in the frequency of para-valvular leak, intra-procedural bleeding, vascular complications, conversion to open-heart surgery, or development of acute kidney injury. The highest in-hospital mortality was observed in the TAo group (TA 2%, TAo 15%, TSub 0%, TCa 2%, P-value = .014). However, hospital length of stay, one-month, and one-year mortality were similar among non-TF techniques. CONCLUSION: Although regional differences exist in the choice of alternative access techniques, centers with high technical expertise can provide a safe alternative to traditional TF TAVR. TAo TAVR was associated with higher in-hospital mortality than other non-TF approaches, and this may have reflected patient rather than procedural factors. All alternative access techniques had similar mortality rates and clinical outcomes at one-year follow-up. Trans-carotid access is safe and feasible compared to other non-TF access techniques.
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Damluji et al. (2018) conducted an observational in Symptomatic severe aortic stenosis (n=172). Non-transfemoral transcatheter aortic valve replacement (TAo, TA, TSub, TCa) vs. Comparison among different non-transfemoral access techniques was evaluated on In-hospital mortality (p=0.014). Trans-aortic TAVR was associated with higher in-hospital mortality (15%) compared to trans-apical (2%), trans-subclavian (0%), and trans-carotid (2%) access (P=0.014).
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