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Transcarotid Approach for TAVR
Study Questions:
What are procedural and clinical outcomes among patients undergoing transcarotid (TC) transcatheter aortic valve replacement (TAVR) using the Edwards Sapien 3 transcatheter valve (THV)?
Methods:
This is a single-center retrospective analysis from the French Transcarotid TAVR registry of 314 patients who underwent TC-TAVR between 2014 and 2018. All patients were ineligible for transfemoral TAVR. Clinical and procedural data were collected prospectively and perioperative and 30-day outcomes according to the updated Valve Academic Research Consortium (VARC-2) are reported.
Results:
The median (interquartile range) age was 83 (78-88) years, 63% were males, and Society of Thoracic Surgeons mortality risk score was 5.8% (4-8.3%). Most patients presented with peripheral artery disease (64%). TC-TAVR was performed under general anesthesia in 91% of cases, mostly using the left carotid artery (73.6%), with a procedural success of 97%. Three annulus ruptures were reported, all resulting in patient death. At 30 days, rates of major bleeding, new permanent pacemaker, and stroke or transient ischemic attack were 4.1%, 16%, and 1.6%, respectively. The 30-day mortality was 3.2%.
Conclusions:
TC-TAVR using the balloon-expandable Edwards Sapien 3 THV is feasible, safe, and effective in select patients as an alternative to the transfemoral approach.
Perspective:
This is the largest report on TC-TAVR in mainly an intermediate-risk cohort of patients. Safety and efficacy including incidence of stroke were comparable to the transfemoral approach. Patients were very carefully screened with computed tomography, Doppler ultrasound, magnetic resonance angiography, and TC Doppler to ensure intact circle of Willis circulation without significant ipsilateral or contralateral disease, and cerebral perfusion was continually monitored during the procedure. Nontransfemoral TAVR identifies a higher-risk cohort, and search for the safest alternative approach continues. Findings from this study of the TC approach are reassuring, but there is a need for expertise and a need for comparison to other alternative routes.
Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and VHD, Interventions and Imaging, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Angiography, Echocardiography/Ultrasound, Magnetic Resonance Imaging
Keywords: Carotid Arteries, Cardiac Surgical Procedures, Geriatrics, Heart Valve Diseases, Heart Valve Prosthesis, Hemorrhage, Ischemic Attack, Transient, Magnetic Resonance Angiography, Pacemaker, Artificial, Peripheral Arterial Disease, Stroke, Transcatheter Aortic Valve Replacement, Ultrasonography, Doppler, Vascular Diseases
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