Evolution of Alternative-access Transcatheter Aortic Valve Replacement

• DOI: 10.1016/j.athoracsur.2021.02.018
• Publication Date: 2021-02-27T08:26:10Z
• Authors: Bogdan Kindzelski; Stephanie L. Mick; Amar Krishnaswamy; Samir R. Kapadia; Tamer Attia; Kevin Hodges; Shirin Siddiqi; Ashley M. Lowry; Eugene H. Blackstone; Zoran Popovic; Lars G. Svensson; Shinya Unai; James J. Yun
• Keywords: Aged, 80 and over; Male; Time Factors; Incidence; Aortic Valve Stenosis; Risk Assessment; 3. Good health; Transcatheter Aortic Valve Replacement; 03 medical and health sciences; Postoperative Complications; Treatment Outcome; 0302 clinical medicine; Surgery, Computer-Assisted; Risk Factors; Aortic Valve; Fluoroscopy; Heart Valve Prosthesis; Humans; Female; Follow-Up Studies; Ohio; Retrospective Studies

Transfemoral access is the most common approach for transcatheter aortic valve replacement (TAVR). However, a subset of patients require alternative access. This study describes the evolution and outcomes of alternative-access TAVR at Cleveland Clinic.From January 2006 to January 2019, 2446 patients underwent TAVR, 414 (17%) through alternative access (247 transapical, 95 transaortic, 56 transaxillary, 2 transcarotid, 10 transiliac, 4 transcaval). Patients undergoing alternative-access TAVR had high preoperative risk. Propensity-matched comparisons were targeted at comparing transfemoral versus transaxillary approaches since 2012.Over time, the favored alternative-access approach shifted from transapical and transaortic to transaxillary. Pacemaker requirement was similar for alternative-access and transfemoral approaches. Compared with transfemoral access, major vascular injuries were higher in the alternative-access group (12 [2.9%] vs 27 [1.3%], P = .02), but minor vascular injuries were lower (13 [3.1%] vs 198 [9.8%], P < .0001). Non-risk-adjusted 5-year survival was lower in the alternative-access group (45% vs 59%). Compared with intrathoracic approaches (transapical and transaortic), transaxillary access was associated with fewer blood transfusions (12 [21%] vs 176 [51%], P < .0001), less prolonged ventilation (1 [1.8%] vs 38 [11%], P = .03), and shorter length of stay (median, 5 vs 7.5 days, P < .0001). Survival and major morbidity were similar in matched comparisons of the transfemoral and transaxillary approaches. No brachial plexus injuries occurred with transaxillary access.The transaxillary approach has emerged as our preferred alternative-access strategy for TAVR. It is associated with superior operative outcomes compared with transthoracic approaches, and results are comparable with those of the transfemoral approach.