Transapical vs. Transfemoral TAVR | Journal Scan
What are the clinical outcomes after transapical (TA) versus transfemoral (TF) transcatheter aortic valve replacement (TAVR), adjusting for characteristics of patients?
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.
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).
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.
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, Atherosclerotic Disease (CAD/PAD), 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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