Study Evaluates Alternative Access for TAVR in Older Adults

July 16, 2018—Results of a collaborative study from France and the United States evaluating alternative access for transcatheter aortic valve replacement (TAVR) in older adults were published by Abdulla A. Damluji, MD, et al in Catheterization and Cardiovascular Interventions. The investigators examined the outcomes of nontransfemoral (non‐TF) TAVR procedures, including transapical (TA), transaortic (TAo), transsubclavian (TSub), and transcarotid (TCa) techniques.

As summarized in Catheterization and Cardiovascular Interventions, the investigators conducted an observational study of all consecutive older patients who underwent non‐TF TAVR for symptomatic severe aortic stenosis with the Edwards Sapien (Edwards Lifesciences), CoreValve (Medtronic), Edwards Sapien 3 (Edwards Lifesciences), or Lotus (Boston Scientific Corporation) valves at three centers in France and the United States from April 2008 to February 2017. Baseline characteristics and clinical outcomes were defined according to VARC‐2 criteria.

The investigators reported that of 857 patients who received TAVR, 172 (20%) had an alternative access procedure: 45 (26%) TA; 67 (39%) TAo; 17 (10%) TSub; and 43 (25%) TCa. The preference for non‐TF access site was different between the two countries (United States: 39%, TA; 52%, TAo; 9%, TSub; 0%, TCa; vs France: 9%, TA; 23%, TAo; 11%, TSub; and 57%, TCa; P < .001).

Most patients who underwent TAo TAVR were older women (median age: 82 years, TA; 84, TAo; 81, TSub; 81, TCa; P = .043; women: 32 [27%], TA; 30 [55%], TAo; 10 [41%], TSub; 27 [37%], TCa; P = .021). The predicted Society of Thoracic Surgery risk of mortality was similar among groups (7%, TA; 7%, TAo; 6%, TSub; 7%, TCa; P = .738).

No differences were observed in the frequency of paravalvular leak, intraprocedural 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 = .014). However, hospital length of stay and 1‐month and 1‐year mortality were similar among non‐TF techniques.

The study demonstrated that 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. Additionally, 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 1‐year follow‐up. TCa access is safe and feasible compared with other non‐TF access techniques, concluded the investigators in Catheterization and Cardiovascular Interventions.