Commentary: An all-access pass to transcatheter aortic valve replacement

Abstract

Central MessageMany alternatives to transfemoral TAVR are available. Patient, operator, and institutional factors should be considered when deciding the optimal access route.See Article page XXX.From the first-in-man description by Cribier and colleagues in 20021Cribier A. Eltchaninoff H. Bash A. Borenstein N. Tron C. Bauer F. et al.Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis: first human case description.Circulation. 2002; 106: 3006-3008Crossref PubMed Scopus (2521) Google Scholar to the most recently published guidelines on valvular heart disease in 2020,2Otto C.M. Nishimura R.A. Bonow R.O. Carabello B.A. Erwin III, J.P. Gentile F. et al.2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines.Circulation. 2021; 143: e72-e227PubMed Google Scholar transcatheter aortic valve replacement (TAVR) has evolved from a niche procedure to a standard intervention. This has revolutionized the treatment of aortic stenosis, but also produced several unanswered questions with regard to valve durability, subclinical leaflet thrombosis, permanent pacemaker insertion with subsequent rehospitalization, the evolving role of TAVR in low-risk patients, and preparing future cardiac surgeons for practices that include transcatheter techniques.3Muller Moran H.R. Eikelboom R. Lodewyks C. Yan W. Zelentsov I. Arora R.C. et al.Two-year outcomes from the PARTNER 3 trial: where do we stand?.Curr Opin Cardiol. 2021; 36: 141-147Crossref PubMed Scopus (6) Google Scholar, 4Muller Moran H.R. Maurice-Ventouris M. Alharbi M. Harley J.M. Lachapelle K.J. A scoping review to identify competencies for transcatheter cardiovascular procedures.J Thorac Cardiovasc Surg. 2020; (XXX:XXX)Abstract Full Text Full Text PDF Scopus (1) Google Scholar, 5Chamandi C. Barbanti M. Munoz-Garcia A. Latib A. Nombela-Franco L. Gutiérrez-Ibanez E. et al.Long-term outcomes in patients with new permanent pacemaker implantation following transcatheter aortic valve replacement.JACC Cardiovasc Interv. 2018; 11: 301-310Crossref PubMed Scopus (93) Google Scholar Naturally, although transfemoral TAVR (TF-TAVR) is the preferred route, questions surrounding the ideal alternative access have persisted for those patients not suitable for TF-TAVR.Junquera and colleagues6Junquera L. Kalavrouziotis D. Dumont E. Rodés-Cabau J. Mohammadi S. Paradigm shifts in alternative access for transcatheter aortic valve replacement: an update.J Thorac Cardiovasc Surg. 2021; (XXX:XXX)Abstract Full Text Full Text PDF Scopus (4) Google Scholar concisely and thoroughly review options for alternative access during TAVR. When available, they provide evidence comparing outcomes after each approach with TF-TAVR and with each other. The number of non–TF-TAVRs performed is not insignificant. Based on the most recent report of the Transcatheter Valve Therapy (TVT) Registry, nearly 3500 individuals underwent non–TF-TAVR in 2019 in the United States alone (~5% of TAVRs performed), whereas almost 27,500 patients have received non–TF-TAVR since the registry's inception in 2011.7Carroll J.D. Mack M.J. Vemulapalli S. Herrmann H.C. Gleason T.G. Hanzel G. et al.STS-ACC TVT Registry of Transcatheter Aortic Valve Replacement.J Am Coll Cardiol. 2020; 76: 2492-2516Crossref PubMed Scopus (221) Google Scholar Thus, whereas the transfemoral approach continues to be the preferred method of TAVR, there is a substantial global need for expertise in alternative access. Certainly, favoring TF-TAVR at all costs is likely to be harmful in a reasonable number of patients.As the authors describe, data on alternative access is inconclusive. They provide a useful decision-making algorithm synthesizing available evidence with reasonable suggestions based on patient-level factors. Yet, patient-level factors represent only 1 potential aspect influencing the choice of access route. According to the TVT registry, the 72,991 individuals who underwent TAVR in 2019 were treated at 669 centers, with an average volume of approximately 109 individuals per center.7Carroll J.D. Mack M.J. Vemulapalli S. Herrmann H.C. Gleason T.G. Hanzel G. et al.STS-ACC TVT Registry of Transcatheter Aortic Valve Replacement.J Am Coll Cardiol. 2020; 76: 2492-2516Crossref PubMed Scopus (221) Google Scholar Is it reasonable to expect the average TAVR center—performing 5 or fewer alternative access TAVRs per year—to replicate the same experience with alternative access as suggested by the literature? The same could be asked of centers with adequate experience and results using any 1 of the available alternative routes because the relationship between surgical volume and outcomes is well known.8Gonzalez A.A. Dimick J.B. Birkmeyer J.D. Ghaferi A.A. Understanding the volume-outcome effect in cardiovascular surgery: the role of failure to rescue.JAMA Surg. 2014; 149: 119-123Crossref PubMed Scopus (181) Google Scholar Obtaining appropriate vascular access and securing adequate closure are among the most commonly identified competencies related to transcatheter procedures,4Muller Moran H.R. Maurice-Ventouris M. Alharbi M. Harley J.M. Lachapelle K.J. A scoping review to identify competencies for transcatheter cardiovascular procedures.J Thorac Cardiovasc Surg. 2020; (XXX:XXX)Abstract Full Text Full Text PDF Scopus (1) Google Scholar further emphasizing the importance of expertise in these procedural elements in both transfemoral and alternative access.3Muller Moran H.R. Eikelboom R. Lodewyks C. Yan W. Zelentsov I. Arora R.C. et al.Two-year outcomes from the PARTNER 3 trial: where do we stand?.Curr Opin Cardiol. 2021; 36: 141-147Crossref PubMed Scopus (6) Google Scholar The safety of any alternative route is therefore likely contingent on institutional and operator experience, with all forms of alternative access (including transthoracic) TAVR capable of being performed safely in experienced hands.We congratulate the authors on an interesting and insightful review. This article will certainly be a useful reference for operators wishing to learn more about and possibly expand their use of alternative TAVR approaches. Cardiac surgeons are critical to obtaining excellent outcomes in alternative access TAVR and thus we should embrace the crucial role we play on multidisciplinary heart teams. Many alternatives to transfemoral TAVR are available. Patient, operator, and institutional factors should be considered when deciding the optimal access route. Many alternatives to transfemoral TAVR are available. Patient, operator, and institutional factors should be considered when deciding the optimal access route. See Article page XXX. See Article page XXX. From the first-in-man description by Cribier and colleagues in 20021Cribier A. Eltchaninoff H. Bash A. Borenstein N. Tron C. Bauer F. et al.Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis: first human case description.Circulation. 2002; 106: 3006-3008Crossref PubMed Scopus (2521) Google Scholar to the most recently published guidelines on valvular heart disease in 2020,2Otto C.M. Nishimura R.A. Bonow R.O. Carabello B.A. Erwin III, J.P. Gentile F. et al.2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines.Circulation. 2021; 143: e72-e227PubMed Google Scholar transcatheter aortic valve replacement (TAVR) has evolved from a niche procedure to a standard intervention. This has revolutionized the treatment of aortic stenosis, but also produced several unanswered questions with regard to valve durability, subclinical leaflet thrombosis, permanent pacemaker insertion with subsequent rehospitalization, the evolving role of TAVR in low-risk patients, and preparing future cardiac surgeons for practices that include transcatheter techniques.3Muller Moran H.R. Eikelboom R. Lodewyks C. Yan W. Zelentsov I. Arora R.C. et al.Two-year outcomes from the PARTNER 3 trial: where do we stand?.Curr Opin Cardiol. 2021; 36: 141-147Crossref PubMed Scopus (6) Google Scholar, 4Muller Moran H.R. Maurice-Ventouris M. Alharbi M. Harley J.M. Lachapelle K.J. A scoping review to identify competencies for transcatheter cardiovascular procedures.J Thorac Cardiovasc Surg. 2020; (XXX:XXX)Abstract Full Text Full Text PDF Scopus (1) Google Scholar, 5Chamandi C. Barbanti M. Munoz-Garcia A. Latib A. Nombela-Franco L. Gutiérrez-Ibanez E. et al.Long-term outcomes in patients with new permanent pacemaker implantation following transcatheter aortic valve replacement.JACC Cardiovasc Interv. 2018; 11: 301-310Crossref PubMed Scopus (93) Google Scholar Naturally, although transfemoral TAVR (TF-TAVR) is the preferred route, questions surrounding the ideal alternative access have persisted for those patients not suitable for TF-TAVR. Junquera and colleagues6Junquera L. Kalavrouziotis D. Dumont E. Rodés-Cabau J. Mohammadi S. Paradigm shifts in alternative access for transcatheter aortic valve replacement: an update.J Thorac Cardiovasc Surg. 2021; (XXX:XXX)Abstract Full Text Full Text PDF Scopus (4) Google Scholar concisely and thoroughly review options for alternative access during TAVR. When available, they provide evidence comparing outcomes after each approach with TF-TAVR and with each other. The number of non–TF-TAVRs performed is not insignificant. Based on the most recent report of the Transcatheter Valve Therapy (TVT) Registry, nearly 3500 individuals underwent non–TF-TAVR in 2019 in the United States alone (~5% of TAVRs performed), whereas almost 27,500 patients have received non–TF-TAVR since the registry's inception in 2011.7Carroll J.D. Mack M.J. Vemulapalli S. Herrmann H.C. Gleason T.G. Hanzel G. et al.STS-ACC TVT Registry of Transcatheter Aortic Valve Replacement.J Am Coll Cardiol. 2020; 76: 2492-2516Crossref PubMed Scopus (221) Google Scholar Thus, whereas the transfemoral approach continues to be the preferred method of TAVR, there is a substantial global need for expertise in alternative access. Certainly, favoring TF-TAVR at all costs is likely to be harmful in a reasonable number of patients. As the authors describe, data on alternative access is inconclusive. They provide a useful decision-making algorithm synthesizing available evidence with reasonable suggestions based on patient-level factors. Yet, patient-level factors represent only 1 potential aspect influencing the choice of access route. According to the TVT registry, the 72,991 individuals who underwent TAVR in 2019 were treated at 669 centers, with an average volume of approximately 109 individuals per center.7Carroll J.D. Mack M.J. Vemulapalli S. Herrmann H.C. Gleason T.G. Hanzel G. et al.STS-ACC TVT Registry of Transcatheter Aortic Valve Replacement.J Am Coll Cardiol. 2020; 76: 2492-2516Crossref PubMed Scopus (221) Google Scholar Is it reasonable to expect the average TAVR center—performing 5 or fewer alternative access TAVRs per year—to replicate the same experience with alternative access as suggested by the literature? The same could be asked of centers with adequate experience and results using any 1 of the available alternative routes because the relationship between surgical volume and outcomes is well known.8Gonzalez A.A. Dimick J.B. Birkmeyer J.D. Ghaferi A.A. Understanding the volume-outcome effect in cardiovascular surgery: the role of failure to rescue.JAMA Surg. 2014; 149: 119-123Crossref PubMed Scopus (181) Google Scholar Obtaining appropriate vascular access and securing adequate closure are among the most commonly identified competencies related to transcatheter procedures,4Muller Moran H.R. Maurice-Ventouris M. Alharbi M. Harley J.M. Lachapelle K.J. A scoping review to identify competencies for transcatheter cardiovascular procedures.J Thorac Cardiovasc Surg. 2020; (XXX:XXX)Abstract Full Text Full Text PDF Scopus (1) Google Scholar further emphasizing the importance of expertise in these procedural elements in both transfemoral and alternative access.3Muller Moran H.R. Eikelboom R. Lodewyks C. Yan W. Zelentsov I. Arora R.C. et al.Two-year outcomes from the PARTNER 3 trial: where do we stand?.Curr Opin Cardiol. 2021; 36: 141-147Crossref PubMed Scopus (6) Google Scholar The safety of any alternative route is therefore likely contingent on institutional and operator experience, with all forms of alternative access (including transthoracic) TAVR capable of being performed safely in experienced hands. We congratulate the authors on an interesting and insightful review. This article will certainly be a useful reference for operators wishing to learn more about and possibly expand their use of alternative TAVR approaches. Cardiac surgeons are critical to obtaining excellent outcomes in alternative access TAVR and thus we should embrace the crucial role we play on multidisciplinary heart teams. Paradigm shifts in alternative access for transcatheter aortic valve replacement: An updateThe Journal of Thoracic and Cardiovascular SurgeryPreviewOver the last decade, transcatheter aortic valve replacement (TAVR) has evolved from a procedure reserved for high-to-prohibitive surgical risk patients,1-3 to an established therapeutic alternative to surgical aortic valve replacement (SAVR) in the low-to-intermediate risk population.4-7 The femoral artery is the first-choice approach whenever possible,8 as this was the predominant access site used in all of the randomized trials comparing TAVR with SAVR. Full-Text PDF