Propensity-Matched Comparisons of Clinical Outcomes After Transapical or Transfemoral Transcatheter Aortic Valve Replacement

Access options for transcatheter mitral valve implantation in patients with prior surgical bioprosthesis

BACKGROUND

Transcatheter mitral valve-in-valve (TMVIV) procedure, either transapical (TA) or trans-septal (TS) has become a valuable alternative to conventional redo surgery in case of failing mitral bioprosthesis with good clinical outcomes. Here we present our fourteen-year institutional experience.

METHODS

All consecutive patients treated with TMVIV with either TA or TS access at our centre between July 2007 and July 2020 were included. Periprocedural and 30-day follow-up (FU) results are reported and TA and TS data are compared.

RESULTS

Eighty-two patients were included, of those 60 (73.2%) were TA while 22 (26.8%) were TS. Men represented 51.2% of the population with a mean age of 77.3±9.0 years. STS score and EuroSCORE II were 11.4%±6.2% and 11.5%±6.5% respectively. Baseline characteristics of TA and TS groups were comparable. TMVIV was performed at a median time of 9.3 years [interquartile range (IQR), 7.9-12.0 days] from the initial mitral valve surgery. Balloon expandable transcatheter heart valve (THV) prostheses (Edwards LifeSciences Corp., Irvine, CA, USA) were used exclusively. Technical success was 97.6% (96.7% and 100.0% for TA and TS respectively) with two (2.4%) periprocedural death, both in the TA group (P=0.533). We observed four (4.9%) left ventricular outflow tract (LVOT) obstructions with one being hemodynamically significant. Six (7.3%) major bleeding occurred in the TA group, not significantly different from TS group (P=0.279). The median length of stay was 6 days (IQR, 4-12 days, 1.5 vs. 7.0 days for TS and TA groups respectively, P=0.001). The overall 30-day mortality rate was 3.7%. We also observed three (3.7%) structural valve deteriorations and in one (1.2%) case the patient required redo mitral surgery at two months. Eighty-seven-point-eight percent of patients were I-II New York Heart Association (NYHA) class. At 30-day FU mean transmitral valve gradient was 7.3±2.7 mmHg and one patient (1.2%) had mitral regurgitation greater than mild. TA and TS groups were comparable.

CONCLUSIONS

Our 14-year single-center experience with TMVIV confirms procedural safety and is an effective alternative to redo surgery with comparable results with both TA and TS. With device, technical improvements and increasing operators' experience, TS is the preferred option for TMVIV. However, in some highly selected patient, TA may still play an important role.

All roads lead to Rome, but some are safer

Since the first in-human implantation, trans-catheter aortic valve replacement (TAVR) has shown an exciting development in both technical and technological terms, becoming the standard of care for many patients, even not only inoperable ones.  Although trans-femoral (TF) access has the scepter of first-line route for TAVR, in some cases, this access is not feasible, so several alternative routes were introduced over time. The network meta-analysis by Hameed et al. has the great merit to provide a comprehensive picture. Hence, through either direct and indirect comparison, the authors confirmed as TF is the gold standard as access, followed by trans-carotid and trans-subclavian. Conversely, trans-thoracic (trans apical and trans-aortic) routes are the least safe and should be reserved only to sporadic cases.

Left Ventricular Apex: A "Minimally Invasive Motorway" for Safe Cardiovascular Procedures

Since the advent of TAVR (transcatheter aortic valve replacement), the transapical surgical approach has been affirmed as a safe and effective alternative access for patients with unsuitable peripheral arteries. With the improvement of devices for transfemoral approach and the development of other alternative accesses, the number of transapical procedures has decreased significantly worldwide. The left ventricular apex, however, has proved to be a safe and valid alternative access for various other structural heart procedures such as mitral valve repair, mitral valve-in-valve or valve-in-ring replacement, transcatheter mitral valve replacement (TMVR), transcatheter mitral paravalvular leak repair, and thoracic aorta endovascular repair (TEVAR). We review the literature and our experience of various hybrid transcatheter structural heart procedures using the transapical surgical approach and discuss pros and cons.

Clinical outcomes after transcatheter aortic valve replacement in South America: A centre-level systematic review and meta-analysis of observational data

OBJECTIVES

To estimate in-hospital and 30-day outcomes after transcatheter aortic valve replacement (TAVR) in South America through a systematic review and meta-analysis of observational data.

METHODS

We comprehensively searched for papers published in peer-reviewed medical journals and for abstracts presented in medical conferences of the region from 1 September 2008, through 29 June 2020, using predefined criteria. We included single-centre studies on TAVR populations with ≥10 patients from South America reporting any in-hospital or 30-day clinical outcome.

RESULTS

Fifty-five cohorts from seven countries, pooling 3001 patients, were included in a random-effects meta-analysis. Self-expandable prostheses were the most frequently implanted. Pooled estimate of procedure success by VARC2 criteria was 90.0% (95%CI 81.8%-94.7%; I² 75.0%). The pooled estimate rates of the outcomes were as follow: post-procedure moderate or severe aortic regurgitation, 9.7% (95%CI 6.0%-15.4%; I² 65.4%), in-hospital cardiac tamponade, 4.0% (95%CI 2.5%-6.6%; I² 0%), in-hospital stroke, 4.1% (95%CI 2.9%-5.7%; I² 0%), in-hospital major vascular complication, 7.8% (95%CI 5.2%-11.5%; I² 22.3%), in-hospital permanent pacemaker implantation, 19.4% (95%CI 15.9%-23.4%; I² 53.8%), in-hospital mortality, 8.0% (95%CI 6.7%-9.6%; I² 0%), and 30-day mortality, 9.7% (95%CI 7.9%-11.8%; I² 26.4%).

CONCLUSION

As compared with published international registries, the overall results of TAVR in South America seemed underrated. Significant heterogeneity was observed in procedural success, pacemaker requirement, and post-procedure moderate or severe aortic regurgitation. This study provides a real-life framework for the analysis of the performance of this technology in the region, intended to be a starting point for quality improvement.

Dose approach matter? A meta-analysis of outcomes following transfemoral versus transapical transcatheter aortic valve replacement

Background

Transcatheter aortic valve replacement (TAVR) has gained increasing acceptance for patients with aortic disease. Both transfemoral (TF-TAVR) and transapical (TA-TAVR) approach were widely adopted while their performances are limited to a few studies with controversial results. This meta-analysis aimed to compare the mortality and morbidity of complications between TF- versus TA-TAVR based on the latest data.

Methods

Electronic databases were searched until April 2021. RCTs and observational studies comparing the outcomes between TF-TAVR versus TA-TAVR patients were included. Heterogeneity assumption was assessed by an I² test. The pooled odds ratios(OR) or mean differences with corresponding 95% confidence intervals (CI) were used to evaluate the difference for each end point using a fixed-effect model or random-effect model based on I² test.

Results

The meta-analysis included 1 RCT and 20 observational studies, enrolling 19,520 patients (TF-TAVR, n = 11,986 and TA-TAVR, n = 7,534). Compared with TA-TAVR, TF-TAVR patients showed significantly lower rate of postoperative in-hospital death (OR = 0.67, 95% CI 0.59–0.77, P < 0.001) and 1-year death (OR = 0.53, 95% CI 0.41–0.69, P < 0.001). Incidence of major bleeding and acute kidney injury were lower and length of hospital stay was shorter, whereas those of permanent pacemaker and major vascular complication were higher in TF-TAVR patients. There were no significant differences between TF-TAVR versus TA-TAVR for stroke and mid-term mortality.

Conclusions

There were fewer early deaths in patients with transfemoral approach, whereas the number of mid-term deaths and stroke was not significantly different between two approaches. TF-TAVR was associated with lower risk of bleeding, acute kidney injury as well as shorter in-hospital stay, but higher incidence of vascular complication and permanent pacemaker implantation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02158-4.

Current Status of Catheter-based Mitral Valve Replacement

PURPOSE OF REVIEW

Transcatheter mitral valve replacement (TMVR) has been developed to address the need for an alternative therapeutic option to surgery in patients suffering from severe mitral regurgitation who are at high surgical risk. The present review illustrated the state-of-the-art of catheter-based mitral valve replacement evaluating technical characteristics and early clinical experience of different devices to outline prospects and challenges of TMVR.

RECENT FINDINGS

Several devices are currently under clinical assessment. Early experience has demonstrated high procedural success of TMVR. However, TMVR faces several possible hurdles such as left ventricular outflow tract obstruction (LVOTO) after prosthesis deployment, access site complications, and thrombotic risk requiring anticoagulatory therapy. Future studies should assess long-term prosthesis stability, optimal anticoagulation regime, and occurrence of paravalvular leakage. The development of smaller TMVR prostheses suitable for transseptal implantation could overcome bleeding complications. In perspective, TMVR may emerge to a clinically relevant therapeutic approach for patients with severe MR at high surgical risk.

Current Therapeutic Options in Aortic Stenosis

Aortic stenosis is the most common valvular disease requiring valve replacement. Valve replacement therapies have undergone progressive evolution since the 1960s. Over the last 20 years, transcatheter aortic valve replacement has radically transformed the care of aortic stenosis, such that it is now the treatment of choice for many, particularly elderly, patients. This review provides an overview of the pathophysiology, presentation, diagnosis, indications for intervention, and current therapeutic options for aortic stenosis.

Transcarotid Versus Transaxillary/Subclavian Transcatheter Aortic Valve Replacement (TAVR): Analysis of Outcomes

Transcatheter aortic valve replacement (TAVR) has revolutionized the percutaneous management of valvular heart disease and has evolved to progressively minimalist techniques over the past decade. This review discusses the impact of minimalist TAVR, explores the alternative approaches when transfemoral (TF) TAVR is not possible, and analyzes the current outcomes of transcarotid (TC) versus transaxillary/subclavian (TAx) TAVR, which are the two leading nonfemoral (NF) approaches emerging as the preferred alternatives to TF TAVR.

Real-Time Monitoring and Step-by-Step Guidance for Transapical Mitral Valve Edge-to-Edge Repair Using Transesophageal Echocardiography

MitraClip edge-to-edge (E2E) repair system is the only transcatheter device recommended in the current guidelines for treating mitral regurgitation (MR). The percutaneous femoral venous transseptal access of MitraClip requires a complex steerable delivery system and may thus be technically complex to optimally position and deploy the clip onto the mitral valve. A transapical approach for E2E repair has been devised to treat MR for the ease of operation (ValveClamp system, Hanyu Medical Technology, Shanghai). The first-in-human study of ValveClamp has demonstrated its early feasibility and effectiveness for the treatment of patients with degenerative MR. Transesophageal echocardiography (TEE) is the only imaging modality required for intraoperative guidance of ValveClamp implantation. Successful implantation depends on accurate localization and orientation of the clamp and efficient intraoperative communication between the echocardiographer and the intervention team. Thus, the focus of this review is on elaborating how two-dimensional (2D) and three-dimensional (3D) TEE are used in clinical practice to guide ValveClamp implantation and it may facilitate the understanding of simplicity and safety of this novel procedure. We also describe the implementation of several novel advancements in 3D TEE imaging, which improve the confidence of image interpretation for intraoperative guidance and expedite implantation times.

Intravascular lithotripsy-assisted balloon angioplasty to facilitate transfemoral transcatheter aortic valve implantation in a patient with coral reef aorta

This case describes the management of a woman in her 70s with severe symptomatic aortic stenosis and concomitant severe stenosis of the suprarenal abdominal aorta due to 'coral reef' calcification of the aortic wall and lumen (CRA). Due to her religious beliefs as a Jehovah's Witness regarding the use of blood products, she rejected the option of surgical aortic valve replacement. Transfemoral (TF) delivery of a transcatheter aortic valve was challenged by the presence of CRA. A successful TF transcatheter aortic valve implantation (TAVI) was achieved by the treatment of the CRA with intravascular lithotripsy-assisted angioplasty, followed by delivery and deployment of a self-expanding TAVI valve.

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.

Minimally-invasive versus transcatheter aortic valve implantation: systematic review with meta-analysis of propensity-matched studies

Background

Minimally invasive aortic valve replacement (MiAVR) and transcatheter aortic valve implantation (TAVI) provide aortic valve replacement (AVR) by less invasive methods than conventional surgical AVR, by avoiding complete sternotomy. This study directly compares and analyses the available evidence for early outcomes between these two AVR methods.

Methods

Electronic databases were searched from inception until August 2019 for studies comparing MiAVR to TAVI, according to predefined search criteria. Propensity-matched studies with sufficient data were included in a meta-analysis.

Results

Eight studies with 9,744 patients were included in the quantitative analysis. Analysis of risk-matched patients showed no difference in early mortality (RR 0.76, 95% CI, 0.37–1.54, P=0.44). MiAVR had a signal towards lower rate of postoperative stroke, although this did not reach statistical significance (OR 0.42, 95% CI, 0.13–1.29, P=0.13). MiAVR had significantly lower rates of new pacemaker (PPM) requirement (OR 0.29, 95% CI, 0.16–0.52, P<0.0001) and postoperative aortic insufficiency (AI) or paravalvular leak (PVL) (OR 0.05, 95% CI, 0.01–0.20, P<0.0001) compared to TAVI, (OR 0.42, 95% CI, 0.13–1.29, P=0.13), while acute kidney injury (AKI) was higher in MiAVR compared to TAVI (11.1% vs. 5.2%, OR 2.28, 95% CI, 1.25–4.16, P=0.007).

Conclusions

In patients of equivalent surgical risk scores, MiAVR may be performed with lower rates of postoperative PPM requirement and AI/PVL, higher rates of AKI and no statistical difference in postoperative stroke or short-term mortality, compared to TAVI. Further prospective trials are needed to validate these results.

Transcatheter Mitral Valve Replacement: An Update on Current Techniques, Technologies, and Future Directions

Growing clinical data support the use of transcatheter therapies for significant mitral valve disease. Currently, edge-to-edge repair is the transcatheter treatment of choice, but many anatomies are not suitable. Transcatheter mitral valve replacement offers several potential advantages over transcatheter repair, most notably a greater and more sustained reduction in mitral regurgitation post-implantation, but also potential disadvantages. To enable the successful treatment of mitral valve disease in a wide range of patients and anatomies, we require an armory of transcatheter devices, including transcatheter mitral valve replacement systems.

Evolution of Alternative-access Transcatheter Aortic Valve Replacement

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Transcatheter and Surgical Aortic Valve Replacement in Patients With Previous Cardiac Surgery: A Meta-Analysis

Background: Many patients who have aortic stenosis and are transcatheter aortic valve replacement (TAVR) candidates have underwent prior cardiac surgery (PCS). The aim of this study was to provide a robust summary comparison between patients with PCS who underwent TAVR vs. surgical aortic valve replacement (SAVR).

Methods: We conducted a systematic review and meta-analysis of all published articles on PubMed/Medline, Ovid, EMBASE, and Scopus from 2002 to 2019.

Results: A total of 13 studies were finally included, yielding a total of 23,148 participants. There was no statistical difference with 30-day [OR: 1.02 (0.86–1.21)] or 1-year mortality [OR: 1.18 (0.86–1.61)] between the two groups. Subgroup analysis revealed that high-risk patients who underwent TAVR with the transapical approach were associated with increased risk of mortality [OR: 1.45 (1.00–2.11)]. However, those who underwent TAVR with endovascular approach had a comparable outcome with SAVR.

Conclusions: Primary outcomes after endovascular TAVR were similar to those with SAVR and superior to transapical TAVR treatment group in patients with PCS.

Transfemoral Transcatheter Tricuspid Valve Replacement With the EVOQUE System: A Multicenter, Observational, First-in-Human Experience

OBJECTIVES

The purpose of this observational first-in-human experience was to investigate the feasibility and safety of the EVOQUE tricuspid valve replacement system and its impact on short-term clinical outcomes.

BACKGROUND

Transcatheter tricuspid intervention is a promising option for selected patients with severe tricuspid regurgitation (TR). Although transcatheter leaflet repair is an option for some, transcatheter tricuspid valve replacement (TTVR) may be applicable to a broader population.

METHODS

Twenty-five patients with severe TR underwent EVOQUE TTVR in a compassionate-use experience. The primary outcome was technical success, with NYHA (NYHA) functional class, TR grade, and major adverse cardiac and cerebrovascular events assessed at 30-day follow-up.

RESULTS

All patients (mean age 76 ± 3 years, 88% women) were at high surgical risk (mean Society of Thoracic Surgeons risk score 9.1 ± 2.3%), with 96% in NYHA functional class III or IV. TR etiology was predominantly functional, with mean tricuspid annular diameter of 44.8 ± 7.8 mm and mean tricuspid annular plane systolic excursion of 16 ± 2 mm. Technical success was 92%, with no intraprocedural mortality or conversion to surgery. At 30-day follow-up, mortality was 0%, 76% of patients were in NYHA functional class I or II, and TR grade was ≤2+ in 96%. Major bleeding occurred in 3 patients (12%), 2 patients (8%) required pacemaker implantation, and 1 patient (4%) required dialysis.

CONCLUSIONS

This first-in-human experience evaluating EVOQUE TTVR demonstrated high technical success, acceptable safety, and significant clinical improvement. Larger prospective studies are needed to confirm durability and safety and the impact on long-term clinical outcomes.

The effect of transcatheter aortic valve implantation approaches on mortality

OBJECTIVES

We aimed to evaluate the effect of transcatheter aortic valve implantation (TAVI) approaches on mortality and identify effect modifiers and predictors for mortality.

BACKGROUND

Alternative access routes to transfemoral (TF) TAVI include the surgical intra-thoracic direct-aortic (DA) and transapical (TA) approach. TA TAVI has been associated with a higher mortality rate. We hypothesized that this is related to effect modifiers, in particular the left ventricular ejection fraction (LVEF).

METHODS

This multicentre study derived its data from prospective registries. To adjust for confounders, we used propensity-score based, stabilized inverse probability weighted Cox regression models.

RESULTS

In total, 5,910 patients underwent TAVI via TF (N = 4,072), DA (N = 524), and TA (N = 1,314) access. Compared to TF, 30-day mortality was increased among DA (HR 1.87, 95%CI 1.26-2.78, p = .002) and TA (HR 3.34, 95%CI 2.28-4.89, p < .001) cases. Compared to TF, 5-year mortality was increased among TA cases (HR 1.50, 95%CI 1.24-1.83, p < .001). None of the variables showed a significant interaction between the approaches and mortality. An impaired LVEF (≤35%) increased mortality in all approaches.

CONCLUSIONS

The surgical intra-thoracic TA and DA TAVI are both associated with a higher 30-day mortality than TF TAVI. TA TAVI is associated with a higher 5-year mortality than TF TAVI. The DA approach may therefore have some advantages over the TA approach when TF access is not feasible.

Midterm outcomes of transaortic and transapical TAVI in patients with unsuitable vascular anatomy for femoral access: A propensity score inverse probability weight study

AIMS

Transaortic (TAo) and transapical (TA) implantation can be used in transcatheter aortic valve implantation (TAVI) when the transfemoral (TF) approach is precluded. We compare the safety and efficacy of these alternative techniques.

METHODS

From October 2007 to February 2016, TAo and TA patients' data were collected. Propensity score inverse probability of treatment weight (IPTW) method was employed to minimize the impact of no-randomization bias.

RESULTS

From our single-center non-TF-TAVI registry, 282 patients were included: 235 (83.3%) underwent TAo and 47 (16.7%) TA. Differences in baseline characteristics were statistically significant in age, sex, risk profile according to logistic-EuroSCORE, and previous cardiac surgery. No difference in hospital morbidity and mortality, but lower stroke-rate in TAo (1.27% vs. 8.5% p < .01) was observed. This was confirmed at logistic regression after IPTW adjustment (odds ratio [OR]: 0.16, 95% CI 0.03-0.71, p = .01), together with reduced risk of the paravalvular leak (PVL) (OR: 0.14, 95% confidence interval [CI]: 0.02-0.81, p = .02). Kaplan-Meier estimates did not demonstrate differences in long-term mortality among access routes (logrank test p = .13). At the IPTW-Cox regression model, long-term mortality was related to New York Heart Association III-IV (hazard ratio [HR]: 2.92, 95% CI: 1.15-7.40, p = .026), chronic renal failure (HR: 3.25; 95% CI: 1.02-10.32 p = .046), previous transient ischemic attack/stroke (HR: 2.29, 95% CI: 1.25-4.20 p = .007). Sapien-3 device resulted to be a protective factor, reducing long-term mortality (HR: 0.18, 95% CI 0.04- 0.90 p = .03).

CONCLUSIONS

TAo is safe and feasible in case of contraindication to femoral approach demonstrating comparable midterm outcomes to TA, thus representing a central access alternative, to increase the overall safety of high-risk TAVI procedures.

A step-by-step guide to transseptal valve-in-valve transcatheter mitral valve replacement

With the recent success of transcatheter aortic valve replacement (TAVR), transcatheter options for the management of mitral valve pathology have also gained considerable attention. Valve-in-valve (ViV) transcatheter mitral valve replacement (TMVR) is one such technique that has emerged as a safe and effective therapeutic option for patients with degenerated mitral valve bioprostheses at high-risk for repeat surgical mitral valve replacement. Several access strategies, including trans-apical, transseptal, trans-jugular, and trans-atrial access have been described for ViV-TMVR. Initial experiences were performed primarily via a trans-apical approach through a left mini-thoracotomy because it offers direct access and coaxial device alignment. With the advancements in TMVR technology, such as the development of smaller delivery catheters with high flexure capabilities, the transseptal approach via the femoral vein has emerged as the preferred option. This technique offers the advantages of a totally percutaneous approach, avoids the need to enter the thoracic cavity or pericardial space, and provides superior outcomes compared to a trans-apical approach. In this review, we outline key aspects of patient selection, imaging, procedural techniques, and examine contemporary clinical outcomes of transseptal ViV-TMVR.

TAVR: A Review of Current Practices and Considerations in Low-Risk Patients

Transcatheter aortic valve replacement (TAVR) is an established treatment for severe, symptomatic, aortic stenosis (AS) in patients of all risk categories and now comprises 12.5% of all aortic valve replacements. TAVR is a less invasive alternative to traditional surgical aortic valve replacement (SAVR), with equivalent or superior outcomes. The use of TAVR has increased rapidly. The success and increase in use of TAVR are a result of advances in technology, greater operator experience, and improved outcomes. Indications have recently expanded to include patients considered to be at low risk for SAVR. While TAVR outcomes have improved, remaining challenges include the management of coexistent coronary artery disease, prevention of periprocedural stroke, and issue of durability. These issues are even more relevant for low-risk, younger patients.

Routine Ultrasound or Fluoroscopy Use and Risk of Vascular/Bleeding Complications After Transfemoral TAVR

OBJECTIVES

This study aimed to examine the benefits of routine use of 2D-US in patients undergoing transfemoral transcatheter aortic valve replacement (TAVR).

BACKGROUND

Two-dimensional ultrasound (2D-US) reduces access-related vascular complications (VCs) and bleeding in patients undergoing percutaneous coronary intervention via transfemoral approach. Potential similar benefits in patients undergoing transfemoral TAVR have not been systemically investigated.

METHODS

Rates of access-related VCs or bleeding were compared using 5-year retrospective observational data from 2 neighboring high-volume UK TAVR centers systemically using 2 different techniques (center 1: fluoroscopy and contralateral angiography [FCA], center 2: 2D-US) for femoral puncture at the time of transfemoral TAVR.

RESULTS

Overall, 1,171 patients were included in the study (FCA, n = 624; 2D-US, n = 529). Baseline clinical and procedural characteristics were similar between the 2 groups. There was no difference in the risk of VCs, bleeding, or their composite according to femoral puncture technique (FCA vs. 2D-US: 6.7% [95% confidence interval (CI): 4.9% to 8.9%] vs. 6.8% [95% CI: 4.8% to 9.3%]; p = 0.63; 6.1% [95% CI: 4.4% to 8.2%] vs. 6.4% [95% CI: 4.8% to 9.3%]; p = 0.70; and 9.8% [95% CI: 7.6% to 12.4%] vs. 9.8% [95% CI: 7.4% to 12.7%]; p = 0.76, respectively) and no difference when analysis was restricted to a composite of major VCs or major and life-threatening bleeding.

CONCLUSIONS

Vascular and bleeding complications can be achieved using either FCA or 2D-US guidance. Further studies are required to identify and assess alternative strategies to reduce periprocedural VCs and bleeding in this patient population.

Simplified Trans-Axillary Aortic Valve Replacement Under Local Anesthesia - A Single-Center Early Experience

BACKGROUND

The axillary artery is an alternative route for patients with comorbidities and unfavorable femoral arteries who need transcatheter aortic valve replacement (TAVR). Simplified trans-axillary transcatheter aortic valve replacement (TAx-TAVR) implies a completely percutaneous approach under local anesthesia and arteriotomy closure with vascular closure techniques. Herein, we report on early experience with simplified TAx-TAVR under local anesthesia.

METHODS

We enrolled all consecutive patients who underwent simplified TAx-TAVR in our center. Main study parameter was the incidence of axillary access related major vascular complications within 30 days. Secondary parameters included a composite early safety endpoint, axillary access-site related vascular/bleeding complications and short-term mortality. Post TAVR axillary stent patency was evaluated during follow-up by CT-analysis.

RESULTS

Between July 2018 and April 2020, Tax-TAVR was attempted in 35 patients with a mean age of 79 years. Local anesthesia and conscious sedation were used in 91.4% (n = 32) and 8.6% (n = 3) respectively. A covered stent was needed for complete axillary hemostasis in 44.1% (n = 15). Device success was achieved in 91.2% (n = 31/34). The 30-day axillary artery major vascular and ≥major bleeding complication rates were 14% (n = 5) and 11% (n = 4). The early safety endpoint was reached in 22.9% (n = 8). Mortality rates at 30 days and six months were 2.9% and 11.6%. Computed tomography (CT) confirmed axillary stent patency during follow-up in 82% (n = 9/11).

CONCLUSIONS

In patients with high/prohibitive surgical risk and unsuitable femoral access, simplified TAx-TAVR under local anesthesia offers a valuable alternative for transfemoral TAVR but requires advanced access site management techniques including covered stents. Our data suggest an unmet clinical need for dedicated TAx closure devices.

Expansion of TAVR into Low-Risk Patients and Who to Consider for SAVR

Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of severe aortic stenosis (AS) over the last decade. The results of the Placement of Aortic Transcatheter Valves (PARTNER) 3 and Evolut Low Risk trials demonstrated the safety and efficacy of TAVR in low-surgical-risk patients and led to the approval of TAVR for use across the risk spectrum. Heart teams around the world will now be faced with evaluating a deluge of younger, healthier patients with severe AS. Prior to the PARTNER 3 and Evolut Low Risk studies, this heterogenous patient population would have undergone surgical aortic valve replacement (SAVR). It is unlikely that TAVR will completely supplant SAVR for the treatment of severe AS in patients with a low surgical risk, as SAVR has excellent short- and long-term outcomes and years of durability data. In this review, we outline the critical role that SAVR will continue to play in the treatment of severe AS in the post-PARTNER 3/Evolut Low Risk era.

Carotid versus femoral access for transcatheter aortic valve implantation: a propensity score inverse probability weighting study

OBJECTIVES

The transcarotid (TC) approach for transcatheter aortic valve implantation (TAVI) is potentially an optimal alternative to the transfemoral (TF) approach. Our goal was to compare the safety and efficacy of TC- and TF-TAVI.

METHODS

Patients who underwent TF-TAVI or TC-TAVI in the prospectively collected FRANCE TAVI registry between January 2013 and December 2015 were compared. Propensity score inverse probability weighting methods were employed to minimize the impact of bias related to non-random treatment assignment.

RESULTS

Of the 11 033 patients included in the current study, 10 598 (96%) underwent a TF-TAVI and 435 (4.1%) had a TC-TAVI. Patients in the TC-TAVI access group presented with a higher risk profile but were significantly younger. There were no differences in the perioperative and 2-year mortality rates after adjustment [odds ratio (OR) 1.02, 95% confidence interval (CI) 0.62-1.68; P = 0.99 and hazard ratio 1.03, 95% CI 0.7-1.35; P = 0.83). TC-TAVI was associated with a significant risk of stroke (OR 2.42, 95% CI 2.01-2.92; P < 0.001), ST-elevation myocardial infarction (OR 7.32, 95% CI 3.87-13.87; P < 0.001), infections (OR 2.36, 95% CI 2.04-2.71; P < 0.001), bleeding (OR 2.01, 95% CI 1.76-2.29; P < 0.001), renal failure (OR 2.23, 95% CI 1.90-2.60; P < 0.001) and need for dialysis (OR 2.36, 95% CI 2.01-2.76, P < 0.001). Conversely, TC-TAVI was not confirmed as a risk factor for pacemaker implantation after adjustment (OR 1.05, 95% CI 0.96-1.15; P < 0.28) and was a protective factor for vascular complications (OR 0.37, 95% CI 0.32-0.43; P < 0.001).

CONCLUSIONS

TC-TAVI is a safe procedure compared to TF-TAVI, although it holds an increased risk of perioperative complications. It should be considered in case of non-femoral peripheral access as the second access choice, to increase the overall safety of TAVI procedures.

A step-by-step guide to trans-axillary transcatheter aortic valve replacement

The application of transcatheter aortic valve replacement (TAVR) has expanded rapidly over the last decade as a less invasive option for the treatment of severe aortic stenosis. In order to perform successful TAVR, vascular access must be obtained with a large-bore catheter to deliver the transcatheter valve to the aortic annulus. Several techniques have been developed for this purpose including transfemoral (TF), trans-aortic, trans-apical, trans-caval, trans-carotid, and trans-axillary (TAx) with varying degrees of success. Among them, TF access is the most common and preferred method owing to its superior and well-established outcomes. However, in the setting of diseased iliofemoral arterial vessels, severe tortuosity, or iliofemoral arteries of insufficient caliber, TF access may not be possible. In these scenarios, one of the aforementioned alternative access routes needs to be considered. TAx-TAVR is an attractive alternative because it can be accomplished via access to a peripheral vessel as opposed to needing to enter the pericardial space or thoracic cavity. In addition, the open surgical cut-down procedure used to expose the axillary artery is familiar to cardiac surgeons who are accustomed to cannulating it for cardiopulmonary bypass. With advancements in TAVR technology including the evolution of delivery systems and corresponding smaller sheath sizes, total percutaneous access via the axillary artery is gaining substantial attention. In this review, we outline key aspects of patient selection, imaging and procedural techniques, and examine contemporary clinical outcomes with this approach.

Transfemoral versus transapical transcatheter aortic valve implantation: a single-centre experience

OBJECTIVES

Transapical transcatheter aortic valve implantation (TAVI) is associated with increased mortality as compared to the transfemoral (TF) access. Possible mechanisms include different patient risk profiles as well as an intrinsic injury caused by the access route itself.

METHODS

All consecutive patients scheduled for TAVI between January 2009 and June 2016 at a single centre were evaluated. A comparison of 30-day mortality and morbidity rates for patients undergoing TF or transapical (TA) TAVI was performed according to the criteria of the Valve Academic Research Consortium 2.

RESULTS

During the investigated period, 1130 patients (TF: n = 619, TA: n = 511) were scheduled for TAVI. TA patients had a higher operative risk profile (logistic EuroSCORE: 24% vs 17%; P < 0.001). Unadjusted 30-day mortality rate was higher in TA than in TF patients, albeit this difference was not significant [TA: 6.7%, TF: 4.8%; odds ratio (OR) 1.3 (0.8-2.3); P = 0.216]. The multivariate logistic regression analysis revealed the logistic EuroSCORE and institutional experience, but not the access mode as independent predictors of 30-day mortality. Major access-site complications occurred with a similar frequency in both groups [TA: 9.4%; TF: 9.2%; OR 1.02 (0.68-1.53); P = 0.915]. Unadjusted long-term mortality rate was higher after TA TAVI. After adjustment, the Cox regression analysis revealed similar long-term mortality rates after TF and TA TAVI [hazard ratio 1.1 (0.88-1.36)].

CONCLUSIONS

The increased mortality of patients undergoing TA TAVI is associated with the patient risk profile and the institutional experience but not with the access mode itself.

Echocardiography-guided subxiphoidal transapical TAVR in a challenging anatomy: a case report

Background

Transcatheter aortic valve replacement (TAVR) via an antegrade transapical access (TA-TAVR) is largely reserved to cases not amenable to transfemoral TAVR. Challenges resulting from unusual thoracic anatomies may require special considerations in terms of the surgical access.

Case presentation

We present a case of TA-TAVR through a subxiphoidal approach in a patient who had undergone extensive thoracic surgery 8 years previously.

Conclusion

Our case demonstrates that unusual anatomic features should not discourage from TA-TAVR but may require unusual approaches designed on a case-to-case basis following careful interdisciplinary preparation and planning including adequate pre-operative diagnostics and imaging.

Comparative Outcomes of Transapical Versus Transfemoral Access for Transcatheter Aortic Valve Replacement in Diabetics

INTRODUCTION

The outcomes of transfemoral (TF) compared with transapical (TA) access for transcatheter aortic valve replacement (TAVR) in diabetics are unknown.

METHODS

We queried the NIS database (2011-2014) to identify diabetics who underwent TAVR. We performed a propensity matching analysis comparing TF-TAVR versus TA-TAVR.

RESULTS

The analysis included 14.555 diabetics who underwent TAVR. After matching, in-hospital mortality was not different between TF-TAVR and TA-TAVR. (3.5 vs. 4.4%, p = 0.11). TF-TAVR was associated with lower rates of cardiogenic shock (2.7 vs. 4.7%, p = 0.02), use of mechanical circulatory support (2.0 vs. 2.9%, p = 0.03), acute renal failure (17.8 vs. 26.5%, p < 0.001), major bleeding (35.8 vs. 40.7%, p < 0.001) and respiratory complications (1.1 vs. 4.4%, p < 0.001) compared with TA-TAVR. However, TF-TAVR was associated with a higher rate of vascular complications (2.9 vs. 0.9%, p < 0.001), cardiac tamponade (0.5 vs. 0.0%, p < 0.001), complete heart block (10.8 vs. 7.7%, p < 0.001) and pacemaker insertion (11.8 vs. 8.3%, p < 0.001). There was no difference between both groups in acute stroke (1.8 vs. 2.2%, p = 0.39), hemodialysis (2.0 vs. 2.2%, p = 0.71), and ventricular arrhythmias (4.9 vs. 4.2%, p = 0.19). Notably, TF-TAVR was associated with higher mortality, acute stroke, AKI, hemodialysis, PCI, and respiratory complications in complicated diabetics compared with non-complicated diabetics.

CONCLUSIONS

This observational analysis showed no difference in-hospital mortality between TF-TAVR and TA-TAVR among diabetic patients. Studies exploring the optimal access for TAVR among diabetics are recommended.

Predictor and Mid-Term Outcome of Clinically Significant Thrombocytopenia After Transcatheter Aortic Valve Selection

BACKGROUND

The frequency and predictors of thrombocytopenia after transcatheter aortic valve implantation (TAVI) are unclear.Methods and Results:This study enrolled 342 patients undergoing TAVI (245 with a percutaneous transfemoral approach, 65 with transfemoral surgical cutdown, and 32 with a non-transfemoral approach). Balloon-expandable and self-expanding valves were implanted in 235 and 107 patients, respectively. Platelet counts started to drop immediately, reaching a nadir 2-4 days after TAVI. Clinically significant thrombocytopenia (CSTP) was defined as a platelet count ≤50×10⁹/L at the time of the nadir or both a platelet count between 80 and 51×10⁹/L and a decrease in platelet count ≥50%. CSTP occurred in 16.7% patients. Approach site and TAVI valve selection significantly predicted CSTP. In multivariate analysis, independent predictors of CSTP were liver cirrhosis (odds ratio [OR] 7.22; 95% confidence interval [CI] 1.05-49.82), baseline platelet count ≤120×10⁹/L (OR 2.98; 95% CI 1.20-7.38), multiple blood transfusions (OR 4.03; 95% CI 1.72-9.41), and the use of balloon-expandable valves (OR 2.38; 95% CI 1.04-5.46). Kaplan-Meier survival analysis with a generalized Wilcoxon test revealed that mid-term (2 years) mortality was greater for patients with than without CSTP (31.4% vs. 15.5%; P=0.008).

CONCLUSIONS

TAVI-related CSTP was not rare and was associated with poor mid-term outcomes. CSTP was not only caused by patients' comorbidities and TAVI complications, but also related to TAVI procedural factors.

Transapical aortic valve replacement versus surgical aortic valve replacement: A subgroup analyses for at-risk populations

BACKGROUND

If the transfemoral access is not feasible, a transapical access or surgical aortic valve replacement (SAVR) are alternatives for patients with aortic valve stenosis.

OBJECTIVES

To identify patient groups who benefit from SAVR or transapical transcatheter aortic valve replacement (TA-TAVR), we compared in-hospital outcomes of patients in a nationwide dataset.

METHODS

We identified 19,016 isolated SAVR and 6432 TA-TAVR performed in Germany from 2014 to 2016. We adjusted for risk factors using a covariate- and propensity-adjusted analysis.

RESULTS

Patients undergoing TA-TAVR were older, had more comorbidities, and accordingly greater estimated operative risk (logistic European System for Cardiac Operative Risk Evaluation 5.3 vs 17.0, P < .001). However, adjusted risk for in-hospital complications such as stroke, acute kidney injury, relevant bleeding, and prolonged mechanical ventilation >48 hours was lower in patients undergoing TA-TAVR (all P < .001). When we compared in-hospital mortality of all patients undergoing either TA-TAVR or SAVR, neither treatment strategy had a clear advantage (covariate-adjusted odds ratio [caOR], 1.13, P = .251; propensity-adjusted OR [paOR], 1.12, P = .309). Two patient subgroups seem to benefit more from SAVR than TA-TAVR: patients <75 years (caOR, 1.29, P = .237; paOR, 2.12, P = .001) and those with European System for Cardiac Operative Risk Evaluation 4-9 (caOR, 1.32, P = .114; paOR, 1.43, P = .041). Female patients had a tendency toward lower risk for in-hospital mortality when undergoing SAVR (caOR, 1.42, P = .030). In patients with chronic renal failure, TA-TAVR was superior (caOR, 0.56, P = .039, P = .040).

CONCLUSIONS

Patients <75 years and those at low operative risk who underwent SAVR had lower in-hospital mortality than those undergoing TA-TAVR. Patients with chronic renal failure who underwent TA-TAVR had lower in hospital mortality than those that underwent SAVR.

Comparing traditional aortic valve surgery and transapical approach to transcatheter aortic valve implant

During the last 15 years, transcatheter aortic valve implant (TAVI) has become a valid alternative to surgical aortic valve replacement in symptomatic patients with severe aortic stenosis, and high or intermediate operative risk. Transcatheter aortic valve implant could be approached through various access sites, among which the transapical has long been one of the most popular. Through the years, this procedure has shown results similar to the standard surgical approach, but not as good as the same procedure via the transfemoral approach. For this reason, along with continuous technological advances, the transfemoral approach is used, presently, in 90% of the patient, while the transapical route has been limited, progressively, to a minority of patients. Currently the Heart Team should decide, in every single patient, between conventional surgery and TAVI. In clinical practice, TAVI is favoured in high-risk patients, and in the elderly at intermediate surgical risk with favourable anatomical features. In patients in whom TAVI is preferable to surgery, but have ‘non-usable’ femoral approach, alternative routes, such as transaxillary or transapical, could be considered.

Intravascular Lithotripsy for Treatment of Calcified, Stenotic Iliac Arteries: A Cohort Analysis From the Disrupt PAD III Study

PURPOSE

The presence of calcification in the iliac arteries is associated with decreased procedural success and increased complication risk during endovascular intervention. The objective of this study was to evaluate the safety and efficacy of peripheral intravascular lithotripsy (IVL) during endovascular treatment of iliac arterial peripheral artery disease (PAD).

METHODS

The Disrupt PAD III Observational Study is a prospective, non-randomized, multi-center single-arm study to assess the 'real-world' safety and effectiveness of the Shockwave Peripheral IVL System for the treatment of de novo calcified lesions in the peripheral arteries, with a goal of treating 1500 patients. This is an analysis of consecutive patients enrolled for treatment of an iliac artery, a specified sub-group, with at least moderate calcification and a minimum length of 20 mm.

RESULTS

Between December 2017 and July 2019, 118 patients with a total of 200 lesions were enrolled across 20 sites. 101 patients were treated primarily for claudication or critical limb ischemia, while 17 patients were treated to optimize the iliac vasculature for large-bore access. All 118 patients had successful IVL catheter delivery. The average reference vessel diameter was 7.3 mm ± 1.9 mm, with an average diameter stenosis of 83.1% ± 13.4% and an average lesion length of 58.3 mm ± 57.6 mm. Severe calcification was present in 82.0% of overall cases. Stent placement was performed in 72.9% of the overall cases. As expected, the access group received less adjunctive therapies including stents (41.2%, p < 0.001). Angiographic complications were minimal with no flow-limiting dissections and a final mean residual stenosis of 12.0% ± 12.1% with no differences between the groups.

CONCLUSIONS

Acute results with IVL in calcified iliac lesions suggest that it is a safe and effective option for calcified, stenotic iliac disease. IVL can be used successfully both for treatment of PAD symptoms and to optimize access for large-bore procedures.

Review of alternative access in transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) has surpassed surgical aortic valve replacement (SAVR) as the most common treatment strategy for severe symptomatic aortic stenosis over the past decade. As TAVR technology has continued to advance, it has been expanded from being an option only for extreme risk patients to now being the preferred option for the majority of patients with severe aortic stenosis. Recent trials have shown that TAVR is superior or non-inferior to SAVR even in patients at low surgical risk. One limitation of TAVR is the need for large bore vascular access. This has improved over time with smaller sheath sizes and improved delivery systems, but is still a significant issue in a patient population that often has many comorbidities including peripheral arterial disease. Early in the TAVR experience the only option for alternative access was transapical access, which has consistently been linked to increased procedural complications and worsened clinical outcomes. However, in recent years several centers have demonstrated the safety and efficacy of several alternative access strategies including transaxillary, transcarotid, transcaval, and direct aortic. There are no randomized data comparing these strategies, so access site approach is chosen by the multidisciplinary heart team based on patient anatomy and site expertise. We will review the current data in alternative access that in our view supports prioritizing a transaxillary or transcarotid strategy. In addition, we will describe our center's pre-procedural planning, peri-procedural approach, and propose an algorithm for alternative access.