Are There Better Outcomes in Transaxillary TAVR vs. Other Approaches?

Patients undergoing balloon-expandable TAVR via transaxillary access may have better 30-day outcomes compared with patients undergoing the procedure via other nontransfemoral approaches, according to a study published April 1 in JACC: Cardiovascular Interventions.

Thom G. Dahle, MD, FACC, et al., used the STS/ACC TVT Registry to evaluate frequency and 30-day outcomes of patients undergoing balloon-expandable TAVR via transfemoral access vs. transaxillary or transapical or transaortic access. In addition, propensity matching was used to compare outcomes in nontransfemoral patients between those receiving transaxillary access vs. those receiving transapical or transaortic access.

A total of 63,581 patients underwent TAVR with the balloon-expandable SAPIEN 3 device between 2015 and 2018. Of these, 3,628 patients had nontransfemoral access, including 1,249 who had transaxillary access, 1,815 had transapical or transaortic access, and 242 had transcarotid access. Results showed that transaxillary TAVR increased during the study period (20.2 percent in 2015 vs. 49 percent in 2017), transapical or transaortic TAVR decreased (61.9 percent in 2015 vs. 35.5 percent in 2017). At 30 days post procedure, the unadjusted mortality rate was 2.4 percent among patients in the transfemoral access group, compared with 5.4 percent in the transaxillary group and 8.5 percent in the transapical or transaortic group.

Among 1,180 propensity-matched pairs, 30-day mortality was significantly lower in the transaxillary group than in the transapical or transaortic group (5.3 percent vs. 8.4 percent), as was new-onset atrial fibrillation (2 percent vs. 13 percent), new dialysis requirements (0.7 percent vs. 2.5 percent), and 30-day readmissions (11.6 percent vs. 15.1 percent). Stroke rates were higher in the transaxillary group compared to the transapical or transaortic group (6.3 percent vs. 3.1 percent).

According to the researchers, the study demonstrates that transaxillary TAVR is "highly successful" for patients without femoral access. They conclude that future research should assess outcomes of other nontransfemoral approaches, such as transcarotid or transcaval, to determine whether transaxillary access should be the preferred method for patients without femoral access.

In an accompanying editorial comment, Vinayak Bapat, MBBS, MS, and Gilbert H. L. Tang, MD, MSc, MBA, FACC, write that the study suggests "excellent outcomes without a learning curve" for transaxillary TAVR, although the increased stroke risk "requires further investigation." Careful patient selection could make the transaxillary approach a "potential default alternative access approach in TAVR," they conclude.

Keywords: Transcatheter Aortic Valve Replacement, Patient Selection, Atrial Fibrillation, Renal Dialysis, Registries, National Cardiovascular Data Registries, STS/ACC TVT Registry

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