Transcarotid Transcatheter Aortic Valve Replacement Research Articles

Transcarotid versus transfemoral transcatheter aortic valve replacement: A systematic review and meta-analysis

BackgroundIn the 2021 Transcatheter Valve Therapy (TVT) registry, 8.9 % of patients underwent TAVR via access sites other than the femoral artery. Transthoracic approaches may be contraindicated in some patients and may be associated with poorer outcomes. Therefore other alternative access routes are increasingly being performed. We conducted a systematic review of the literature on transcarotid transcatheter aortic valve replacement (TC-TAVR) and meta-analysis comparing outcomes of TC-TAVR and other access routes. MethodsWe comprehensively searched for controlled randomized and non-randomized studies from 4 online databases. We presented data using risk ratios (95 % confidence intervals) and measured heterogeneity using Higgins' I2. ResultsSixteen observational studies on transcarotid TAVR were included in the analysis; 4 studies compared TC-TAVR vs TF-TAVR. The mean age and STS score for patients undergoing TC-TAVR were 80 years and 7.6 respectively. For TF-TAVR patients, mean age and STS score were 81.2 years and 6.5 respectively. There was no difference between patients undergoing TC-TAVR and TF-TAVR in the following 30-day outcomes: MACE [8.4 % vs 6.7 %; OR 1.32 (95 % CI 0.71–2.46 p = 0.38) I2 = 0 %], mortality [5.6 % vs 4.0 %; OR 0.42 (95 % CI 0.60–3.37, P = 0.42) I2 = 0 %] and stroke [0.7 % vs 2.3 %; OR 0.49 (95 % CI 0.09–2.56, P = 0.40) I2 = 0 %]. There was no difference in 30-day major vascular complications [0.7 % vs 3 %; OR 0.55 (95 % CI 0.06–5.29, P = 0.61) I2 = 39 %], major bleeding [0.7 % vs 3.8 %; OR 0.39 (95 % CI 0.09–1.67, P = 0.21) I2 = 0 %], and moderate or severe aortic valve regurgitation [8.6 % vs 9.9 %; OR 0.89 (95 % CI 0.48–1.65, P = 0.72) I2 = 0 %]. ConclusionThere are no significant differences in mortality, stroke MACE and major or life-threatening bleeding or vascular complications when TC-TAVR is compared to TF-TAVR approaches.

Outcomes of Alternative Access Transcatheter Aortic Valve Replacement Procedures.

Alternative access transcatheter aortic valve replacement (TAVR) consists primarily of 4 different options: transcaval, transaxillary, transcarotid, and transapical. While many centers have a preferred alternative access site, few papers have compared the outcomes of TAVR with each alternative access site. In this review, we examine the outcomes of TAVR at each alternative access site, focusing on mortality, stroke, bleeding, pacemaker insertion, paravalvular leakage, and discharge to home. Notable findings include higher mortality in the transapical group and higher stroke rate in the transaxillary group. On the basis of these data, we suggest that transcarotid TAVR might represent the second choice of approach for TAVR when alternate access is required.

Transcarotid Transcatheter Aortic Valve Replacement for Severe Aortic Valve Stenosis with Narrow Aortic Root and Shaggy Aorta: A Case Report

Objective: Transcarotid access for transcatheter aortic valve replacement (TAVR) is a minimally invasive alternative approach if femoral access becomes unfavorable; however, it remains off-label use in Japan.Case Presentation: An 85-year-old female patient with severe aortic valve stenosis presented to our hospital and was diagnosed with acute heart failure. The Society of Thoracic Surgery score and the European System for Cardiac Operative Risk Evaluation 2 were 9.5% and 11.2%, respectively. Computed tomography revealed a small aortic annulus (annulus axis diameter: 18.5 mm × 22.8 mm, perimeter: 67.5 mm, area: 359 mm2), small aortic roots (Valsalva: noncoronary cusp, 22.7 mm; right coronary cusp, 22.8 mm; left coronary cusp, 24.3 mm; sinotubular junction: 18.5 mm × 22.8 mm), and a shaggy aorta with bilateral subclavian artery stenoses. Optimal medical therapy did not work well; therefore, we performed balloon aortic valvuloplasty (BAV). However, BAV did not improve aortic stenosis and worsened aortic regurgitation. The heart team decided to perform transcarotid TAVR owing to the presence of almost no plaque in the left common carotid artery (CCA), and brain magnetic resonance angiography revealed good communications between the anterior and posterior communicating arteries. On the 10th hospital day, transcarotid TAVR was performed, and Sapien 3 20-mm valve was directly implanted during the 30-min clamp time of the left CCA. The procedure was successful, and the clinical course following TAVR was good. Finally, she was discharged to her home on the 24th hospital day.Conclusion: We experienced a successful transcarotid TAVR case. Transcarotid access is a feasible approach in a case requiring an alternative approach.

Carotid ultrasound following transcarotid transcatheter aortic valve replacement

BackgroundTranscarotid (TC) is a common alternative access for transcatheter aortic valve replacement (TAVR) when the transfemoral route is not suitable. However, scarce data exist on systematic ultrasound (US) follow-up of these patients. This study aims to evaluate the safety of TC-TAVR using pre-and post-procedure carotid artery US assessment. MethodsWe performed an observational prospective study including 50 consecutive patients who underwent TC-TAVR that had a follow-up at our institution between September 2016 and July 2020. ResultsAll patients had a carotid US examination at a median time of 13 months (IQR: 5–17) following the procedure. Thirty-six (71%) patients also had a US examination prior to the procedure. Mean pre-procedural access route common carotid artery (AR-CCA) peak systolic velocity (PSV) was 62.9 cm/s (SD:16.8) vs. 69.0 cm/s (SD: 53.4) in the contralateral CCA (CL-CCA), p = 0.562). There was a significant increase in post-procedural PSV values in the AR-CCA (30.3 cm/s (SD: 36.3), p < 0.001) but not in the CL-CCA (5.8 cm/s (SD: 51.7), p = 0.503). Two new carotid stenoses (4%) were diagnosed after the procedure. No baseline or procedural variables were associated with a higher increase in carotid flow velocities at follow-up. There were no cerebrovascular events related to these findings after a median follow-up of 29 months (IQR:13–33). ConclusionsTC-TAVR was associated with a mild but significant increase in carotid flow velocities, with new significant (>50%) carotid stenosis diagnosed in 4% of patients. These findings were not associated with clinical events after a median follow-up of 2 years. Further studies are warranted.

Transcarotid Transcatheter Aortic Valve Replacement With Simple “Flip-n-Flex” Technique

Transcarotid transcatheter aortic valve replacement (TAVR) is increasingly accepted as a safe and efficacious alternative when transfemoral access is contraindicated. Technical and anatomic considerations unique to transcarotid access warrant several adaptations to the routine TAVR procedure. This report describes an approach to overcome these challenges and improve efficiency, including adoption of the "flip-n-flex" technique originally developed for right transaxillary TAVR. This technique has been used at Tufts Medical Center (Boston, MA) since 2019 in both left and right transcarotid TAVR approaches with success to ensure coaxial alignment of the transcatheter heart valve to the aortic root.

Cranial nerve injury during transcarotid transcatheter aortic valve replacement

BackgroundNo data exist about cranial nerve injury (CNI) as a potential complication of transcarotid (TC) transcatheter valve replacement (TAVR). MethodsThis monocentric study included 318 consecutive patients undergoing TC-TAVR from May 2015 to August 2021. ResultsCNI occurred in 7 (2.2%) TAVR-TC patients. Five out of the 7 patients (71.4%) had an injury of the laryngeal branch of the vagus nerve, and 2 patients (28.6%) had an injury of the facial nerve. The majority of patients were male (85.7%), with high body mass index (35.6 (IQR: 30.1–37.3) kg/m2). The induced disabilities were clinically important especially for patients with dysphonia. ConclusionsCNI is a potential complication of TC-TAVR likely avoidable by a meticulous surgical technique. Structural heart teams must be aware of this serious setback.

Alternate accesses for transcatheter aortic valve replacement: A network meta-analysis.

When transfemoral (TF) access is contraindicated in patients undergoing transcatheter aortic valve replacement (TAVR), alternate access strategies are considered. The choice of one alternate access over the other remains controversial. Following a comprehensive literature search, studies comparing any combination of TF, transapical (TA), transaortic (TAo), transcarotid (TC), and trans-subclavian (TS) TAVR were identified. Data were pooled using fixed- and random-effects network meta-analysis. Rank scores with probability ranks of different treatment groups were calculated. Eighty-four studies (26,449 patients) were included. Compared to TF access, TA and TAo accesses were associated with higher 30-day mortality (odds ratio [OR] 1.60, 95% confidence interval [CI] 1.31-1.94; OR 1.79, 95% CI 1.21-2.66, respectively), while the TC and TS showed no difference (OR 1.12, 95% CI 0.64-1.95; OR 1.23, 95% CI 0.67-2.27, respectively); TF access ranked best followed by TC. There was no significant difference in 30-day stroke; TC access ranked best followed by TS. At a weighted mean follow-up of 1.6 years, TA and TAo accesses were associated with higher long-term mortality versus TF (incidence rate ratio [IRR] 1.31, 95% CI 1.18-1.45; IRR 1.41, 95% CI 1.11-1.79, respectively); there was no difference between TC and TS versus TF access (IRR 1.02, 95% CI 0.70-1.47; IRR 1.16, 95% CI 0.82-1.66, respectively); TF access ranked best followed by TC. At a weighted mean follow-up of 1.4 years, only TA access was associated with higher long-term stroke compared to TF (IRR 3.01, 95% CI 1.15-7.87); TF access ranked as the best strategy followed by TAo. TC and TS approaches are associated with superior postoperative outcomes compared to other TAVR alternate access strategies. Randomized trials definitively assessing the safety and efficacy of alternate access strategies are needed.

Association between Stroke and Carotid Artery Blood Block Interval in Trans-Carotid Transcatheter Aortic Valve Replacement: A Retrospective Observational Study

Objectives: Patients undergoing trans-carotid transcatheter aortic valve replacement (TC-TAVR) are more likely to suffer from a stroke because of cerebral blood hypoperfusion and blood occlusion caused by the introducer sheath compared with the trans-femoral (TF) approach. The present study aimed to compare the incidence of stroke between the TC and TF approaches and explore the causes of stroke after TAVR. Methods: We retrospectively reviewed the medical records of 414 consecutive patients with severe aortic valve stenosis who underwent TC- or TF-TAVR at our center from October 2010 to November 2019; these patients were included in this observational study. The clinical data, such as the incidence of stroke, were compared between TC- and TF-TAVR patients. The correlation between carotid artery blood block interval (CABBI) and neurological events was also analyzed. The study was approved by the Ethics Committee of Zhongshan Hospital of Fudan University (approval No. YL2014-32). Results: Patients undergoing TC-TAVR had a significantly higher incidence of stroke than those undergoing TF-TAVR (12.5% vs. 0, P 0.05). Moreover, in TC-TAVR patients, the average CABBI of stroke was significantly longer than that of nonstroke patients (61.7 ± 20.7 min vs. 25.1 ± 1.6 min, P = 0.001). The number of patients with CABBI >30 min in the stroke group was greater than that in the nonstroke group (P

A meta-analysis of transcarotid versus transfemoral transcatheter aortic valve replacement.

Carotid access has shown promise as an excellent delivery route for transcatheter aortic valve replacement (TAVR). We aimed to compare outcomes of transcarotid (TC) and transfemoral (TF) TAVR by conducting a search and analysis of the best evidence in the literature to shed light on its safety and effectiveness. The PubMed/MEDLINE, Embase, and Cochrane library from inception to July 2020 were searched to identify articles reporting comparative data on TC versus TF approaches for TAVR. Patients' baseline characteristics and clinical outcomes were extracted from the articles and pooled for analysis. Five studies, including a total of 2470 patients, were included in the study with 1859 patients in the TF group and 611 patients in the TC group. The TC group had higher prevalence of peripheral vascular disease, while the patients in the TF group was older. Meta-analysis revealed that there was no significant differences between the two groups with regard to 30-day mortality (p=0.09), stroke (p=0.28), new dialysis (p=0.58), major bleeding (p=0.69), or pacemaker implantation (p=0.44). The TF group had a higher incidence of vascular complications (3.9% vs. 2.3%; OR 2.22; 95% CI [1.13, 4.38]; p=0.02). Compared with the TF approach, TC-TAVR is associated with comparable procedural and clinical outcomes. Our analysis found a lower rate of vascular complication in TC access compared with TF access. This supports consideration of such an alternative access when there are concerns over the feasibility of TF access.

Carotid versus femoral access for transcatheter aortic valve replacement: comparable results in the current era.

The carotid approach for transcatheter aortic valve replacement (TAVR) has been shown to be feasible and safe. The goal of this study was to compare the 30-day outcomes of trans-carotid (TC) and transfemoral (TF) TAVR. This retrospective study enrolled 500 consecutive patients treated by TC-TAVR (n = 100) or TF-TAVR (n = 400) with percutaneous closure between January 2018 and January 2020 at the Nantes University Hospital. The primary end-point was the occurrence of cardiovascular death and cerebrovascular events at 30 days. The mean age was 79.9 ± 8.1 in the TC group and 81.3 ± 6.9 (P = 0.069) in the TF group. The TC group had more men (69% vs 50.5%; P = 0.001) and more patients with peripheral vascular disease (86% vs 14.8%; P < 0.0001). Cardiac characteristics were similar between the groups, and the EuroSCORE II was 3.8 ± 2.6% vs 4.6 ± 6.0%, respectively (P = 0.443). The 30-day mortality was 2% in the TC group versus 1% in the TF group (P = 0.345). TC-TAVR was not associated with an increased risk of stroke (2% vs 2.5%; P = 0.999) or major vascular complications (2% vs 4%; P = 0.548). More permanent pacemakers were implanted in the TF group (14.9% vs 5.6%; P = 0.015), and no moderate or severe aortic regurgitation was observed in the TC group (0 vs 3.3%; P = 0.08). TC-TAVR was not associated with an increased risk of mortality or stroke at 30 days (odds ratio 1.32; 95% confidence interval 0.42-4.21; P = 0.63) in the multivariable analysis. No statistically significant differences between TC-TAVR and TF-TAVR were observed; therefore, TC-TAVR should be the first alternative in patients with anatomical contraindications to the femoral route.

Comparable Outcomes for Transcarotid and Transfemoral Transcatheter Aortic Valve Replacement at a High Volume US Center

With continued growth of transcatheter aortic valve replacement (TAVR), safe alternative access remains important for patients without adequate transfemoral (TF) access. Registry-based outcomes with transcarotid (TC) TAVR are favorable compared to transapical or transaxillary/subclavian, but TC vs TF comparisons have not been made. Our objective was to compare outcomes between TF and TC access routes for TAVR at a high-volume United States center. Methods: We retrospectively evaluated all TF and TC TAVR procedures from June 11, 2014 (first TC case) through December 31, 2019. The primary outcomes were 30-day stroke and 30-day mortality. Secondary outcomes were 1-year stroke, 1-year survival, and 30-day and 1-year life-threatening/major bleeding, vascular complications, and myocardial infarction. Propensity score weighted (PSW) models were used to compare risk-adjusted TF and TC outcomes. Of 1,465 TAVR procedures, 1319 (90%) were TF and 146 (10%) were TC. Procedure time and length of stay did not differ between groups. Unadjusted 30-day stroke (TF = 2.0%, TC = 2.7%, P = 0.536) and mortality (TF = 2.1%, TC = 2.7%, P = 0.629) were similar between groups. PSW 30-day stroke (odds ratio (OR) (95% confidence interval (CI)) = 0.8 (0.2-2.8)) and mortality (OR (95% CI) = 0.8 (0.2-3.0)) were similar between groups. Unadjusted and PSW 30-day major/life threatening bleeding, major vascular complications, and myocardial infarction did not differ between groups. Survival at one year was 90% (88%-92%) for TF patients and 87% (81%-93%) for TC patients (unadjusted P = 0.28, PSW hazard ratio = 1.0 (0.6-1.7)). Transcarotid TAVR is associated with similar outcomes compared to transfemoral TAVR at an experienced, high-volume center.

Transcarotid versus transthoracic access for transcatheter aortic valve replacement: A propensity-matched analysis.

Transcarotid access for transcatheter aortic valve replacement is emerging as an alternative to more traditional nonfemoral access options such as transapical or transaortic; however, comparative data are limited. The purpose of the study was to analyze outcomes after transcatheter aortic valve replacement using transcatheter compared with transthoracic (transapical/transaortic) access. The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry was queried for patients who underwent transcarotid, transapical, or transaortic transcatheter aortic valve replacement with the SAPIEN 3 (Edwards Lifesciences, Irvine, Calif) transcatheter heart valve between June 2015 and July 2019. Thirty-day unadjusted outcomes were evaluated, and propensity score matching and logistic regression were used to compare transcatheter access with transthoracic access. In the propensity-matched analysis, 667 transcarotid transcatheter aortic valve replacement procedures were compared with 1334 transthoracic procedures. Transcarotid transcatheter aortic valve replacement was associated with lower mortality (4.2% vs 7.7%, P=.004), less new-onset atrial fibrillation (2.2% vs 12.1%, P<.0001), fewer readmissions at 30days (9.8% vs 16.1%, P=.0006), shorter median length of stay (3.0 vs 6.0days, P<.0001), shorter median intensive care unit stay (25 vs 47.2hours, P<.0001), and greater 30-day Kansas City Cardiomyopathy Questionnaire score improvement from baseline (25.1 vs 20.8, P=.007). Stroke (4.3% vs 3.7%, P=.44) and major vascular complications (1.4% vs 1.9%, P=.40) were similar. Transcatheter aortic valve replacement using transcarotid access is associated with lower 30-day mortality, less atrial fibrillation, shorter intensive care unit and overall length of stay, fewer readmissions, greater improvement in Kansas City Cardiomyopathy Questionnaire scores, and no significant difference in stroke or major vascular complications compared with transthoracic access.

Radiation Exposure During Transcatheter Aortic Valve Replacement: Impact of Arterial Approach and Prosthesis Type

The impact of novel alternative access and valve type on radiation exposure during transcatheter aortic valve replacement (TAVR) has not yet been evaluated. This study sought to determine the impact of a transarterial approach and prosthesis type on physician and patient exposure to radiation during TAVR. This was a prospective study including 140 consecutive patients undergoing TAVR by transfemoral (n= 102) or transcarotid (TC) (n= 38) access at 2 centers. Implanted valves were the self-expanding Evolut R/PRO system (Medtronic, Minneapolis, MN; n= 38) and the balloon-expandable SAPIEN 3 valve (Edwards Lifesciences, Irvine, CA; n= 102). The primary endpoint was first operator radiation exposure. The secondary endpoint was patient radiation exposure. First operator radiation exposure was 4-fold greater during TC TAVR (P < .001). The use of a self-expanding valve was associated with a longer x-ray time (P= .015) and a 2-fold greater first operator radiation dose (P= .018). Patient radiation dose was not significantly affected by arterial approach (P= .055) or valve type (P= .095). After adjustment for potential confounders, the TC approach remained associated with a 174.8% (95% confidence interval, 80.6-318.3, P < .001) increase in first operator radiation dose, whereas the use of a self-expanding valve no longer influenced the first operator dose (P= .630). TC access and the use of a self-expanding valve were associated with a 4- and 2-fold greater first operator radiation exposure during TAVR procedures, respectively. Unlike the arterial approach, the effect of bioprosthesis type on radiation exposure was mainly related to x-ray time and was no longer significant after adjustment.

Ultrasound-Guided Intermediate Cervical Plexus Block for Transcarotid Transcatheter Aortic Valve Replacement

To report the authors' initial experience of transcarotid transcatheter aortic valve replacement (TAVR) managed with ultrasound-guided intermediate cervical plexus block. A single-center prospective study. A teaching hospital in Paris, France. All consecutive patients undergoing a transcarotid TAVR were included. The ultrasound-guided intermediate cervical plexus block was performed in 28 of 31 patients. In 3 patients, the procedure was scheduled under general anesthesia: 2 because of failure of previous transfemoral procedures under local anesthesia, and 1 for an emergency procedure in a pulmonary edema context. Anesthesia and all perioperative parameters were recorded, as well as any complications after the procedure. Twenty-eight patients were managed with intermediate cervical plexus block and light sedation without any anesthesia-related complication. No conversion to general anesthesia was required. The use of vasopressor was only required in 11% of the patients. In 2 patients, a loss of consciousness after the common carotid artery cross-clamping test occurred, leading to the use of a temporary femoral-carotid shunt; no other change in consciousness was recorded during the procedure. Ultrasound-guided intermediate cervical plexus block appeared to be an alternative anesthetic technique for carotid TAVR, providing adequate surgical conditions, continuous neurologic monitoring, and arterial pressure stability.

Transcarotid Versus Subclavian/Axillary Access for Transcatheter Aortic Valve Replacement With SAPIEN 3

Subclavian/axillary (TAx) access has become the most frequently used alternative access route for transcatheter aortic valve replacement (TAVR). Transcarotid (TC) TAVR has grown in popularity recently. Comparative data between these 2 contemporary access methods is lacking. Data were extracted from The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy (TVT) Registry™ (June 2015 to October 2019) for patients undergoing TAVR by TC or TAx access with the SAPIEN 3 and SAPIEN 3 Ultra (Edwards Lifesciences, Irvine, CA) transcatheter heart valves. Procedural, index hospitalization, and 30-day outcomes were analyzed for TC vs TAx groups after 1:2 propensity matching of patient baseline characteristics. The study included 3903 cases, of which 801 TC and 3102 TAx procedures were compared. After 1:2 propensity matching, TC TAVR was associated with similar 30-day mortality (4.3% vs 5.2%, P= .34) but a significantly lower risk of stroke (4.2% vs 7.4%; hazard ratio, 0.56; 95% confidence interval, 0.38-0.83; P= .003) compared with TAx access. Other outcomes that favored TC over TAx included shorter procedure time (117.0 vs 132.4 minutes; P < .001) and fluoroscopy time (16.6 vs 21.6 min; P < .001), lower contrast volume (78.5 vs 96.7 mL; P < .001), shorter length of stay in the intensive care unit (24.3 vs 25.0 hours; P= .02) and hospital (2.0 vs 3.0 days; P= .002), and more patients discharged to home (82.9% vs 74.6%; P < .001). TC TAVR is associated with similar mortality and a significant reduction in stroke compared with the TAx approach. If femoral access is precluded, TC may be a safe, or at times, preferred avenue of transcatheter valve delivery.

Cerebral Embolism After Transcarotid Transcatheter Aortic Valve Replacement: Factors Associated With Ipsilateral Ischemic Burden

Transcarotid transcatheter aortic valve replacement (TAVR) recipients may be exposed to a higher ipsilateral subclinical cerebral ischemic burden compared with the contralateral hemisphere. We sought (1) to compare the cerebral ischemic burden of the 2 hemispheres after transcarotid TAVR, as evaluated by diffusion weighted-magnetic resonance imaging (DW-MRI), and (2) to identify the factors associated with ipsilateral ischemic burden. This prospective study included 52 patients undergoing transcarotid TAVR, followed by a DW-MRI examination. All DW-MRIs were analyzed offline by a radiologist blinded to the clinical data. TAVR was performed through the left (n= 50) or right (n= 2) carotid artery. Procedural success was achieved in all patients, carotid dissection requiring patch closure occurred in 1 patient, and there were no periprocedural stroke events. At least 1 cerebral ischemic lesion was identified in the ipsilateral and contralateral hemisphere in 84.6% and 63.5% of patients, respectively (P= .005), and the number of ischemic lesions per patient was higher in the ipsilateral vs the contralateral hemisphere (2 [interquartile range, 1-5] vs 1 [interquartile range, 0-3], P= .005). The lesion volume (per lesion) and the average lesion volume (per patient) did not differ between the 2 hemispheres. A larger sheath/catheter size (≥18F vs ≤16F) was associated with a higher ipsilateral ischemic burden (P= .026). Carotid artery access for TAVR was associated with a higher number of cerebral ischemic lesions in the ipsilateral (vs contralateral) cerebral hemisphere. The use of a larger sheath/delivery system (≥18F) was associated with an increased ipsilateral ischemic burden.

Short term Outcomes of Transcarotid vs Transaxillary Artery TAVR Procedures: A Single Center Experience

Objective: Patients with prohibitive iliofemoral disease undergoing transcatheter aortic valve replacement (TAVR) often require alternative, nonfemoral access for valve delivery and implantation. To date, there is a paucity of data directly comparing the transcarotid and trans-subclavian access routes. We thus sought to evaluate the short-term outcomes of both approaches. Methods: All TAVR procedures performed via a transcarotid or trans-subclavian approach between June 2015 and May 2019 were included. Data were retrospectively collected from The Society of Thoracic Surgeons/American College of Cardiology (STS/ACC) Transcatheter Valve Therapy (TVT) Registry. Outcomes are reported in accordance with the Valve Academic Research Consortium definitions. Results: A total of 131 patients were treated with either transcarotid or trans-subclavian TAVR during the study period (transcarotid=57 vs. trans-subclavian=74). Transcarotid patients had higher Society of Thoracic Surgeons risk scores (14.87±7.58 vs. 11.42±7.52; p=0.018) and prevalence of hypertension (100% vs. 89%; p=0.010). Trans-subclavian patients had higher rates of prior coronary interventions (43% vs. 26%; p=0.045). The transcarotid approach exhibited shorter fluoroscopy time (minutes, 22.55±8.12 vs. 33.62±13.94; p<0.001) and lower contrast volume (milliliter, 92.95±46.15 vs. 113.28±55.00; p=0.026). ICU stay and overall hospital stay were shorter with the transcarotid approach, (hours, 24.9 vs. 72.7; p=0.03) and (days, 5.86±5.56 vs. 8.95±8.23; p=0.016). There were no differences between the groups with respect to 30-day mortality (0% vs. 5.4%; p=0.132), stroke (7% vs. 8%; p=0.816), need for permanent pace-maker or vascular complication. Conclusions: The transcarotid approach yields lesser fluoroscopy time, contrast volume, ICU and overall hospital stay compared to the trans-subclavian approach. Short-term mortality and stroke rates are similar between the two approaches. KEYWORD: e-P-22 The authors do not declare any conflict of interest.

Transcarotid Versus Transapical and Transaortic Access for Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) using transcarotid access may improve outcomes compared with transapical or transaortic access. This study retrospectively evaluated 165 patients who were undergoing alternate access TAVR using transcarotid (n= 84), transapical (n= 48), and transaortic (n= 33) access. The 30-day outcomes and 2-year Kaplan-Meier survival were analyzed using a multivariable Cox proportional hazards model. The median Society of Thoracic Surgeons predicted risk of mortality was similar among patients treated by transcarotid, transapical, and transaortic access (9.0% [interquartile range (IQR), 6.6, 12.0] vs 9.1% [IQR, 7.0, 11.7] vs 10.0% [IQR, 8.5, 13.0]; p= 0.14), respectively. Patients treated with transcarotid TAVR had a trend toward lower 30-day mortality (3.6% [3 of 84] vs 6.3% [3 of 48] vs 15.2% [5 of 33]; p= 0.09) and significantly better 2-year survival (88.4% vs 79.2% vs 63.6%; p= 0.004) compared with patients treated by transapical and transaortic access, respectively. In addition, transcarotid access was associated with a shorter median length of stay (3.0 days [IQR, 2.0, 5.0] vs 6.5 days [IQR. 5.0, 9.5] vs 7.0 days [IQR, 5.0, 9.0]; p < 0.001), lower transfusion rate (4.8% [4 of 84] vs 12.0% [12 of 48] vs 24.2% [8 of 33]; p < 0.001), higher likelihood of discharge to home without home health care (89.3% [75 of 84] vs 54.2% [26 of 48] vs 42.4% [14 of 33]; p < 0.001), and similar 30-day stroke rates (2.4% [2 of 84] vs 2.1% [1 of 48] vs 3.0% [1 of 33];p= 0.9). Transcarotid compared with transapical and transaortic access for TAVR is associated with shorter length of stay, fewer transfusions, more frequent discharge to home, and better 2-year survival.

Transcarotid Approach for Transcatheter Aortic Valve Replacement With the Sapien 3 Prosthesis: A Multicenter French Registry

ObjectivesThis study sought to describe the procedural and clinical outcomes of patients undergoing transcarotid (TC) transcatheter aortic valve replacement (TAVR) with the Edwards Sapien 3 device. BackgroundThe TC approach for TAVR holds the potential to become the optimal alternative to the transfemoral gold standard. Limited data exist regarding safety and efficacy of TC-TAVR using the Edwards Sapien 3 device. MethodsThe French Transcarotid TAVR prospective multicenter registry included patients between 2014 and 2018. Consecutive patients treated in 1 of the 13 participating centers ineligible for transfemoral TAVR were screened for TC-TAVR. Clinical and echocardiographic data were prospectively collected. Perioperative and 30-day outcomes were reported according to the updated Valve Academic Research Consortium (VARC-2). ResultsA total of 314 patients were included with a median (interquartile range) age of 83 (78 to 88) years, 63% were males, Society of Thoracic Surgeons mortality risk score 5.8% (4% to 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%. ConclusionsTC-TAVR using the Edwards Sapien 3 device was safe and effective in this prospective multicenter registry. The TC approach might be considered, in selected patients, as the first-line alternative approach for TAVR whenever the transfemoral access is prohibited. Sapien 3 device was safe and effective in our multicenter cohort.

Successful transcarotid transcatheter aortic valve replacement in a 34-kg patient with Schimke immuno-osseous dysplasia and severe biscuspid aortic stenosis

We present the case of transcatheter aortic valve replacement in a 20-year-old woman with severe bicuspid aortic stenosis and Schmike immuno-osseous dysplasia who was unfit for surgical aortic valve replacement. Meticulous pre-procedural planning and a multidisciplinary team approach can enable successful transcatheter aortic valve replacement in complex patients with genetic syndromes.