Long‐term outcomes associated with the transaortic approach to transcatheter Aortic valve replacement

Abstract

Objective We investigated the long‐term safety, efficacy and clinical outcomes associated with transaortic (TAO) transcatheter aortic valve replacement (TAVR) in the United States. Background We previously reported the technical feasibility and short‐term safety of TAO TAVR. Compared to transapical (TAP) access, the TAO approach was associated with shorter median intensive care unit (ICU) length of stay (LOS) and more favorable technical learning curve. However, outcomes data beyond 30 days were lacking and the longer‐term clinical consequences of this strategy were unknown. Methods Mortality outcomes at 1 year (and longer) of 44 consecutive patients who underwent TAO TAVR in our institution were compared with that of 76 consecutive patients who underwent TAP TAVR at our site. Risk‐adjusted analysis was performed in propensity‐matched patients (25 from each group) to account for baseline differences. Results TAO TAVR was associated with a trend towards lower all‐cause mortality at 1 year compared to TAP TAVR (18% vs. 34%, P=0.09 in the overall sample; 12% vs. 40%, P = 0.05 in the matched cohort). The higher probability of survival with TAO TAVR persisted after a median follow‐up period of 23 months (hazard ratio [HR]=1.96, P = 0.06 in the overall sample; HR = 3.4, P = 0.01 in the matched cohort). Cardiovascular mortality at 1 year was lower with TAO TAVR (2% vs. 22%, P = 0.01 in the overall sample; 4% vs. 28%, P = 0.05 in the matched cohort). ICU LOS (shorter in the TAO group) and implantation of second prosthetic valve (higher incidence in the TAP group) were independent predictors of long‐term mortality. Conclusion The outcomes associated with TAO TAVR compare favorably with TAP TAVR. Our results appear to corroborate the long‐term safety and efficacy of the TAO approach in TAVR patients with inadequate iliofemoral access. © 2015 Wiley Periodicals, Inc.

Outcomes, readmissions, and costs in transfemoral and alterative access transcatheter aortic valve replacement in the US Medicare population

“…CPB has been associated with increased mortality in the large clinical trials and commercial use in the United States. 6,27,28 This study confirms a similar finding of worse outcomes associated with CPB use, but also provides new information regarding the costs of CPB to the hospital and to society in the form of Medicare payments. CPB use varied in this study by TAVR access, with TA patients requiring significantly more CPB use compared with TF and TAO patients, similar to results reported by Thourani and colleagues.…”

Alternative access for transcatheter aortic valve replacement in older adults: A collaborative study from France and United States

“…Compared to other access sites, the TAo approach was associated with the highest in‐hospital mortality (15%), which is also similar to the initial TAo experience reported from one large academic center . In that study, in‐hospital mortality of 14% was ascribed to the selection of high surgical risk patients for the TAo approach, with an estimated mean Society of Thoracic Surgery risk of mortality of 8% .…”

“…Alternative techniques for transcatheter valve deployment were developed in parallel with the TF approach, and are also generally safe and feasible . These non‐TF approaches include trans‐aortic (TAo), apical (TA), subclavian (TSub), carotid (TCa), and caval‐aortic (TC‐Ao) .…”

Transapical and Transaortic Transcatheter Aortic Valve Replacement in the United States

“…Modern all-cause 30-day mortality rates for TF TAVR have been reported to be 1.7% to 17.5% [10], whereas the same range is reported to be 5.7% to 17.5% for TA TAVR [11][12][13] and 7.4% to 14% for TAo TAVR [14][15][16]. Outcomes between patients operated on with the TA or TAo have been comparable in previous series [14,16]; however, a recent report suggested a survival advantage for TAo compared with TA at 1 year (mortality 18% versus 34%) in a propensity matched analysis [17].…”