Propensity-Matched Comparisons of Clinical Outcomes After Transapical or Transfemoral Transcatheter Aortic Valve Replacement

Abstract

Background— The higher risk of adverse outcomes after transapical (TA) versus transfemoral (TF) transcatheter aortic valve replacement (TAVR) could be attributable to TA-TAVR being an open surgical procedure or to clinical differences between TA- and TF-TAVR patients. We compared outcomes after neutralizing patient differences using propensity score matching. Methods and Results— From April 2007 to February 2012, 1100 Placement of Aortic Transcatheter Valves (PARTNER)-I patients underwent TA-TAVR and 1521 underwent TF-TAVR with Edwards SAPIEN balloon-expandable bioprostheses. Propensity matching based on 111 preprocedural variables, exclusive of femoral access morphology, identified 501 well-matched patient pairs (46% of possible matches), 95% of whom had peripheral arterial disease. Matched TA-TAVR patients experienced more adverse procedural events, longer length of stay (5 versus 8 days; P <0.0001), and slower recovery (New York Heart Association class I, 31% versus 38% at 30 days, equalizing by 6 months at 51% versus 47%); stroke risk was similar (3.4% versus 3.3% at 30 days and 6.0% versus 6.7% at 3 years); mortality was elevated for the first 6 postprocedural months (19% versus 12%; P =0.01); but aortic regurgitation was less (34% versus 52% mild and 8.9% versus 12% moderate to severe at discharge, P =0.001; 36% versus 50% mild and 10% versus 15% moderate to severe at 6 months, P <0.0001). Conclusions— The likelihood of adverse periprocedural events and prolonged recovery is greater after TA-TAVR than TF-TAVR in vasculopathic patients after accounting for differences in cardiovascular risk factors, although stroke risk is equivalent and aortic regurgitation is less. As smaller delivery systems permit TF-TAVR in many of these patients, we recommend a TF-first access strategy for TAVR when anatomically feasible. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00530894.

Thirty-Day Readmissions After Transcatheter Aortic Valve Replacement in the United States

“…However, TA-TAVR is associated with higher mortality and prolonged recovery when compared with TF-TAVR, and unlike TF-TAVR, health-related quality of life after TA-TAVR is no better than SAVR. 19,20 Our study showed that TA-TAVR is also associated with an increased risk of 30-day readmission. This association may be influenced by residual confounding as patients undergoing TA-TAVR are typically sicker with more complex PVD that cannot be captured completely in an administrative database such as the NRD.…”

Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk Patients

“…A previous study involving high-risk patients treated with TAVR also showed higher rates of adverse periprocedural events and death among propensitymatched patients who underwent transapical access than among those who underwent transfemoral access. 28 Further studies would be needed to explore the hypothesis that in intermediaterisk patients who are not candidates for TAVR with transfemoral access, TAVR with transthoracic access may have similar or worse outcomes than surgery.…”

Insights Into Timing, Risk Factors, and Outcomes of Stroke and Transient Ischemic Attack After Transcatheter Aortic Valve Replacement in the PARTNER Trial (Placement of Aortic Transcatheter Valves)

“…In PARTNER, unadjusted stroke risk was higher after TA-than after TF-TAVR; however, after adjusting for baseline characteristics, risk was similar. 23 Other studies and meta-analyses have shown no difference in stroke risk based on access site. 24 Risk of stroke after TAVR has decreased over time, though less pronounced in the TF group, 3,25 where evolution of the delivery system and refined patient selection may have contributed to a decrease.…”