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Comparison of Transfemoral Transcatheter Aortic Valve Replacement Performed in the Catheterization Laboratory (Minimalist Approach) Versus Hybrid Operating Room (Standard Approach): Outcomes and Cost Analysis
Study Questions:
Can transfemoral transcatheter aortic valve replacement (TAVR) be performed safely without general anesthesia, transesophageal echocardiography, or a hybrid operating room?
Methods:
This retrospective study examined 142 patients at a single center undergoing transfemoral TAVR using a minimally invasive approach (MA-TAVR) versus a standard approach (SA-TAVR). The MA-TAVR was performed using local anesthesia, conscious sedation, percutaneous access and closure, and transthoracic echocardiography. All procedures utilized a balloon-expandable valve (Edwards SAPIEN). Outcomes including mortality, stroke, intensive care unit time, length of stay, and cost were compared between groups. All patients initially underwent SA-TAVR, and during the latter part of the study, MA-TAVR became the dominant and default approach.
Results:
Between patients undergoing MA-TAVR (n = 70) and SA-TAVR (n = 72), there were no differences in age (82 ± 8 vs. 83 ± 8 years, p = 0.58), male gender (61% vs. 53%, p = 0.29), or Society of Thoracic Surgeons predicted risk of mortality (10.6 ± 4.3 vs. 11.4 ± 5.8%, p = 0.35). Between MA-TAVR and SA-TAVR cases, there were no differences for procedure success (100% vs. 96%, p = 0.24), in-hospital mortality (0% vs. 4%, p = 0.24), 30-day mortality (0% vs. 6%, p = 0.12), or 30-day stroke (4% vs. 1%, p = 0.35). Patients treated with MA-TAVR had shorter length of stay (4 vs. 6 days, p = 0.01), shorter intensive care time (22 vs. 28 hours, p < 0.001), and lower costs ($45,485 ± 14,397 vs. $55,377 ± 22,587, p < 0.001). There was no difference in survival at the median follow-up of 435 days (83% for MA-TAVR and 82% for SA-TAVR, p = 0.64).
Conclusions:
The authors concluded that MA-TAVR can be performed safely in selected patients, and may result in decreased costs and a shorter hospital stay.
Perspective:
There is growing interest in MA-TAVR for femoral access as sites gain experience and its use becomes more widespread. These findings demonstrate that MA-TAVR is feasible in many patients planned for femoral access, and may potentially reduce costs and duration of hospital stay. These findings represent a retrospective analysis of results from a single center that initially used SA-TAVR in all patients, and subsequently defaulted to MA-TAVR for most transfemoral cases (but not all). It is important to acknowledge that this site had increased experience during the MA-TAVR period than the SA-TAVR period, which may introduce some bias. While these results are encouraging, adequately powered randomized trials are needed to determine the outcomes of a strategy that defaults to MA-TAVR as compared to SA-TAVR for cases using femoral access.
Keywords: Intensive Care Units, Stroke, Follow-Up Studies, Hospital Mortality, Conscious Sedation, Echocardiography, Transesophageal, Length of Stay
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