Transapical vs. Transfemoral TAVR | Journal Scan

Study Questions:

What are the clinical outcomes after transapical (TA) versus transfemoral (TF) transcatheter aortic valve replacement (TAVR), adjusting for characteristics of patients?

Methods:

The investigators used data from the PARTNER-I trial. From April 2007 to February 2012, 1,100 PARTNER-I patients underwent TA-TAVR and 1,521 TF-TAVR using Edwards SAPIEN balloon-expandable bioprostheses. To address confounding due to differing baseline patient characteristics, the investigators adopted propensity-score–based matching.

Results:

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 (PAD). Matched TA-TAVR patients experienced more adverse procedural events, longer length of stay (5 vs. 8 days, p < 0.0001), and slower recovery (New York Heart Association class I 31% vs. 38% at 30 days, equalizing by 6 months at 51% vs. 47%); stroke risk was similar (3.4% vs. 3.3% at 30 days and 6.0% vs. 6.7% at 3 years); mortality was elevated for the first 6 post-procedure months (19% vs. 12%, p = 0.01), but aortic regurgitation was less (34% vs. 52% mild and 8.9% vs. 12% moderate-severe at discharge, p = 0.001; 36% vs. 50% mild and 10% vs. 15% moderate-severe at 6 months, p < 0.0001).

Conclusions:

The authors concluded that 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.

Perspective:

This subgroup analysis reports that in matched patients with similar degrees of PAD and extensive cardiovascular risk factors, TA-TAVR is associated with greater periprocedural morbidity and mortality than TF-TAVR. This was true overall as well as in propensity-matched comparisons. The mechanism for this increased early risk requires further study to identify possible ways to mitigate or reduce it. At this time, based on available data, a transfemoral preferred strategy for TAVR seems to be prudent whenever anatomically feasible.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and VHD, Interventions and Structural Heart Disease, Interventions and Vascular Medicine

Keywords: Transcatheter Aortic Valve Replacement, Aortic Valve Insufficiency, Bioprosthesis, Peripheral Arterial Disease, Peripheral Vascular Diseases, Risk, Risk Factors, Stroke, Propensity Score, Mortality


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