Alternate accesses for transcatheter aortic valve replacement: a retrospective single-center study

Transapical Versus Transfemoral Aortic Valve Implantation: A Comparison of Survival and Safety

Invited Commentary

Direct Comparison of Feasibility and Safety of Transfemoral Versus TransaorticVersus Transapical Transcatheter AorticValve Replacement.

Myocardial Injury After Transaortic Versus Transapical Transcatheter Aortic Valve Replacement

Transcatheter aortic valve implantation is an alternative therapy for surgery in patients with aortic stenosis having high risk for surgery. Transcatheter aortic valve implantation may be performed through transfemoral, transaortic and transapical approaches. General anesthesia is generally required for transapical and transaortic approaches while epidural anesthesia is enough for the transfemoral approach. Although transfemoral access is suitable for most cases, patients having severe vascular tortuosity are candidates for the transapical approach. However, the approach for patients having vascular tortuosity along with poor respiratory capacity contraindicated for general anesthesia is controversial. Vascular complications that significantly increase patient morbidity and mortality are common in transfemoral transcatheter aortic valve implantation and generally associated with severe ilio-femoral tortuosities, severe calcification, porcelain aorta, and significant atheroma of the femoral and iliac vessels. But the effect of tortuosity alone was not evaluated well and complications were generally associated with vascular calcification. Stiff wires were commonly used in endovascular procedures. The vascular tortuosity can be straightened with stiff wires but the accordion effect, pseudo obstruction and vascular injury may also be observed. Herein we present a case of severe aortic stenosis successfully treated with transfemoral aortic valve implantation despite severe femoral, iliac and aortic tortuosity having severe chronic obstructive pulmonary disease.

Senile calcific aortic stenosis (AS) is the most common acquired valvular heart disease with an increasing prevalence attributable to an aging population. Survival is poor in patients with severe or critical AS, chiefly after the onset of symptomology that primarily includes angina, dyspnea, or syncope. On the onset of symptoms, mortality occurs at very high rates during the ensuing 2 to 3 years.1 Until recently, surgical aortic valve replacement represented the sole therapy that definitive reduced mortality and morbidity in patients with severe symptomatic AS, with medical therapy generally ineffective of these patients. Given the advanced age commonly associated with severe AS, a high proportion of these patients are denied surgical intervention because of multiple comorbidities and excessively high surgical risk.2 Recently, transcatheter aortic valve replacement (TAVR) has emerged as a novel disruptive technology that serves an alternative therapy to surgical AVR and has been shown to be an effective therapy in nonoperable and high-risk patients with severe symptomatic AS.3,4 TAVR was first described in humans by Cribier et al in 20025 by a transvenous approach delivered in an antegrade fashion. This technique requires a transseptal puncture and passage of the aortic stent valve across the mitral valve to the aortic position. Subsequently, array of alternative transvascular approaches have arisen, including transfemoral, transaortic, trans-subclavian, and aortic methods. Of these, the retrograde transarterial approach through the femoral artery, developed by Webb et al,6 has been the commonly used approach, with >60 000 such procedures performed worldwide to date. To date, the global experience with TAVR as documented in both single and multicenter registries as well as through multicenter trials have shown good clinical outcomes with improvement in hemodynamic and clinical status, establishing TAVR to be a feasible alternative therapy to traditional surgical aortic valve …

Background: Transcatheter Aortic valve replacement (TAVR) has emerged as new technique for the management of patient with severe Aortic Stenosis (AS). Stroke is a potential complication associated with the procedure, when performed via both transfemoral (TF) and transapical approach (TA). Due to limited data, we performed a comprehensive meta-analysis comparing 30-day and 1-year stroke rates with TAVR performed using TF vs TA approach. Methods: We searched SCOPUS since inception to July 2014 using pre-defined criteria. The cerebrovascular event rates and type were estimated at different time points using standard random effects model. Results: 5 studies, with total 1956 valves placed, reported 30-day stroke rates with TA approach, and 9 studies, with 1146 valves, reported stroke rates with TF approach. No significant difference (p=0.313) was noted with TA vs TF approach with stroke rates 1.74 (0.61-2.87), 1.52 (0.71-2.33) respectively (Figure 1, Panel A). Similarly, 4 studies, with total 1657 valves, reported 1-year stroke rates with TA approach, and 8 studies, with 1034 valves, reported stroke using TF approach. Again, no significant difference (p=0.161) was noted with TA vs TF approach with adjusted stroke rates 3.78 (1.72-5.85), 3.11 (1.49-4.74) respectively (Figure 1, Panel B). Conclusion: We did not observe any difference in stroke rates when TAVR is performed using transapical versus transfemoral approach.

Surgical replacement of aortic valve is the gold standard therapy for severe aortic valve stenosis. Transcatheter Aortic Valve Implantation (TAVI) is less invasive and becomes an alternative therapy reserved for patients with high operative risk. TAVI can be performed via transfemoral, transapical or transaortic approach. Patients with diseased or difficult femoral/iliac vascular access, poor left ventricular function and significant respiratory disease are not suitable for transfemoral or transapical approach. In this scenario, direct transaortic approach of TAVI is a feasible option. This case report presents a case of a 76-year-old man with symptomatic severe aortic valve stenosis who underwent general anaesthesia and was successfully treated by direct transaortic TAVI using Edwards Sapien XT aortic bioprosthesis.

Background: Transfemoral valve implantation is the most widely used approach for transcatheter aortic valve implantation (TAVI) and transapical approach is considered to be associated with increased morbidity and mortality. The aim of our study was to compare TAVI related complications in trasfemoral and transapical approach and to compare the long-term outcome in these two groups. Methods and results: We enrolled 171 patients who underwent transfemoral or transapical TAVI between October 2009 and January 2015 (143 transfemoral approach, 28 transapical approach). Patients with transapical approach were more often men and more of them had coronary artery disease and carotid stenosis. The most common complications were related to vascular damage that resulted in minor bleeding and were more common in transfemoral approach. There were no other significant differences in periprocedural complications between transfemoral and transapical site of implantation. We observed no statistical difference in 30 days survival between transfemoral and transapical approach, but long-term survival was better with the transfemoral approach (log Rank = 0.025). Conclusions: We observed comparable results with transfemoral and transapical TAVI approach. The long-term survival, which was better in transfemoral group, could be improved with valve and access route individualization to each patient's anatomy and general condition.

The Axillary/Subclavian Artery Access Route for Transcatheter Aortic Valve Replacement: A Systematic Review of the Literature

2018 AATS/ACC/SCAI/STS Expert Consensus Systems of Care Document: Operator and Institutional Recommendations and Requirements for Transcatheter Aortic Valve Replacement: A Joint Report of the American Association for Thoracic Surgery, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, and The Society of Thoracic Surgeons

Comparison of the surgical and transcatheter aortic valve replacement in high-risk patients

165 Non-randomised comparison of 30-day safety and effectiveness of surgical aortic valve replacement and transcatheter aortic valve implantation for high risk patients with severe aortic stenosis

Recommendations for Transesophageal Echocardiographic Screening in Transcatheter Aortic Valve Replacement: Insights for the Cardiothoracic Anesthesiologist

Beyond the hammer: The future of cardiothoracic surgery