Transfemoral Access Not Only Option for TAVR

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Less than half of inoperable patients undergoing transcatheter aortic valve replacement (TAVR) are eligible for the transfemoral approach, according to a study published online October 1, 2013, ahead of print in the Annals of Thoracic Surgery. As such, operators should be comfortable performing the procedure via multiple access routes, the authors suggest.

Vinod H. Thourani, MD, of Emory University Hospital (Atlanta, GA), and colleagues retrospectively analyzed 44 TAVR procedures (40.9% transfemoral) using the Sapien valve (Edwards Lifesciences, Irvine, CA) at their institution from November 2011 to April 2012. Nontransfemoral procedures included the transapical (25%), transaortic (27.3%), and transcarotid (0.07%) approaches.

The nontransfemoral group received platelets at a higher rate than the transfemoral group (19.2% vs. 0; P = 0.048). No patients had greater than mild perivalvular leak after implantation, and intraoperative vascular complications occurred in 11.4%.

Echocardiographic measures were similar between the transfemoral and nontransfemoral groups. There were substantial drops in aortic valve gradient and in maximum velocity across the aortic valve, while aortic annular area increased postoperatively.

No postoperative stroke or MI was seen. Two patients (4.5%) with preoperative conduction disease had complete heart block postoperatively and required permanent pacemaker placement. Two patients in the transfemoral arm died intraoperatively, but the 30-day mortality rates between the treatment arms did not differ (table 1).

Table 1. Postoperative Outcomes by TAVR Approach

 
Patients implanted via a nontransfemoral approach had longer median postoperative hospital stays compared with those who underwent a transfemoral procedure (5.5 vs. 3.0 days; P = 0.022), although length of stay in the ICU and mean postoperative ventilator time did not differ between the groups.

Multiaccess Approach Enables Tailored Treatment

“The large number of patients who cannot receive [transfemoral] TAVR argues strongly for the need for alternative approaches,” Dr. Thourani and colleagues write.

The low mortality rates are “excellent, especially when compared with the expected mortality of patients treated medically, [and they] also indicate that alternative access routes can have results similar to those seen in the [transfemoral] route,” they add.

“Our experience demonstrated that cardiac surgeons and cardiologists must utilize a multitude of access options in TAVR to achieve minimal morbidity and mortality with excellent outcomes,” Dr. Thourani said in a press release. “What we have learned from this study is that the TAVR physician, be it a cardiologist or cardiac surgeon, should feel comfortable utilizing a variety of TAVR techniques. This will allow the most appropriate tailoring of the TAVR procedure for optimal patient outcomes.”

Study Details

Mean age was 76.6 years in the nontransfemoral group and 80.5 years in the transfemoral group (P = 0.22). There were more women implanted via a nontransfemoral vs. femoral approach (46.2% vs. 16.7%; P = 0.043). Nontransfemoral patients had higher preoperative LVEF (0.523 ± 0.110 vs. 0.379 ± 0.193; P = 0.009) and were more likely to have peripheral vascular disease (80.8% vs. 33.3%; P = 0.002). However, the transfemoral group had a higher rate of prior cardiac operations (83.3% vs. 46.2%; P = 0.013).

 

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Source:
Thourani VH, Gunter RL, Neravetla S, et al. Use of transaortic, transapical, and transcarotid transcatheter aortic valve replacement in inoperable patients. Ann Thorac Surg. 2013;96:1349-1357.

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