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Yamani N, Ali SH, Sadiq M, Ahmed AB, Bhojwani KD, Lohana VP, Fatmah S, Khalid S, Shamsi HR, Zehra B, Fatima K, Baloch ZQ. Trans-femoral versus trans-carotid access for transcatheter aortic valve replacement: an updated systematic review and meta-analysis. Future Sci OA 2024; 10:FSO930. [PMID: 38817364 PMCID: PMC11137775 DOI: 10.2144/fsoa-2023-0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 10/27/2023] [Indexed: 06/01/2024] Open
Abstract
Aim: This meta-analysis aims to shed light on any primacy the trans-carotid (TC-TAVR) access may have over the trans-femoral access (TF-TAVR) for those undergoing transcatheter aortic valve replacement (TAVR). Methods: PubMed/MEDLINE and Cochrane Library were searched, from inception to March 2023 retrieving seven adjusted studies with a total of 6609 patients, of which 5048 underwent TF-TAVR while 1561 underwent TC-TAVR. Results: No divergence in risk of mortality, major bleeding or stroke/transient ischemic attack in TC-TAVR when compared with TF-TAVR was found. In TC-TAVR, the risk of vascular complications was low (OR: 0.51, 95% CI: 0.32-0.83, p = 0.003) as compared with TF-TAVR. Conclusion: As of this analysis, the viability of TC-TAVR as first alternative to TF-TAVR is plausible.
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Affiliation(s)
- Naser Yamani
- Division of Cardiology, University of Arizona Phoenix Medical Center, AZ 85721, USA
| | - Syed Hasham Ali
- Faculty of Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, 74200, Pakistan
| | - Mahnoor Sadiq
- Faculty of Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, 74200, Pakistan
| | - Afeera B Ahmed
- Faculty of Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, 74200, Pakistan
| | - Kapil D Bhojwani
- Faculty of Medicine, Dow International Medical College, Dow University of Health Sciences, Karachi, 74200, Pakistan
| | - Vivek P Lohana
- Faculty of Medicine, Dow International Medical College, Dow University of Health Sciences, Karachi, 74200, Pakistan
| | - Saba Fatmah
- Faculty of Medicine, Karachi Medical & Dental College, Karachi, 74700, Pakistan
| | - Shazra Khalid
- Faculty of Medicine, Sindh Medical College, Jinnah Sindh Medical University, Karachi, 75510, Pakistan
| | - Hammad R Shamsi
- Faculty of Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, 74200, Pakistan
| | - Batool Zehra
- Faculty of Medicine, Karachi Medical & Dental College, Karachi, 74700, Pakistan
| | - Kaneez Fatima
- Faculty of Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, 74200, Pakistan
| | - Zulfiqar Q Baloch
- Division of Cardiology, Sparrow Hospital, Michigan State University, MI 48912, USA
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Moccetti F, Wolfrum M, Bossard M, Attinger-Toller A, Loretz L, Cuculi F, Toggweiler S. Transfemoral-only transcatheter aortic valve replacement: A single center experience of 400 consecutive patients. Catheter Cardiovasc Interv 2024. [PMID: 38736247 DOI: 10.1002/ccd.31077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 04/30/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND In transcatheter aortic valve replacement (TAVR), transfemoral (TF) access offers several advantages over alternative access routes. Advances in sheaths and valve delivery technology have catalyzed the feasibility of TF-TAVR, even in challenging anatomies. AIMS Report procedural characteristics and outcomes of a TAVR program aiming for a 100% TF access rate. METHODS Consecutive patients undergoing TAVR were enrolled in a prospective registry. Equipment used to facilitate TF-access in challenging anatomies included low-profile sheaths, dilatators, peripheral balloons, covered and uncovered self-expanding and balloon-expandable stents, and intravascular lithotripsy (IVL). RESULTS A total of 400 patients with a mean age of 81 ± 6 years (42% female) were analyzed. Minimal iliofemoral artery diameter (MLD) of the main access side was <5 mm in 42 (10.5%), extreme tortuosity was present in 65 (16.3%), and severe calcification in 59 (14.8%). TF-access was successful in 399 (99.8%) patients. A transaxillary access was used in one patient. In multivariable analysis, an MLD < 5 mm was the strongest predictor for vascular complications (11.9% vs. 3.9%, OR: 3.86, 95% CI: 1.38-10.8, p = 0.01). Such patients also had more major/life-threatening bleeding (14.2% vs. 3.1%, p < 0.001) and required more planned and unplanned peripheral interventions to enable TF access (35.8% vs. 3.4%, p < 0.001). CONCLUSION Our study shows that utilization of dedicated sheaths, peripheral balloons, stents, and IVL enables TAVR via TF access in >99% of patients. However, rates of vascular and bleeding complications in patients with narrow iliofemoral arteries (MLD < 5 mm) were high.
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Affiliation(s)
- Federico Moccetti
- Heart Center Lucerne, Cardiology, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Mathias Wolfrum
- Heart Center Lucerne, Cardiology, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Matthias Bossard
- Heart Center Lucerne, Cardiology, Luzerner Kantonsspital, Lucerne, Switzerland
| | | | - Lucca Loretz
- Heart Center Lucerne, Cardiology, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Florim Cuculi
- Heart Center Lucerne, Cardiology, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Stefan Toggweiler
- Heart Center Lucerne, Cardiology, Luzerner Kantonsspital, Lucerne, Switzerland
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Yokoyama Y, Sakata T, Mikami T, Misumida N, Scotti A, Takagi H, Sugiura T, Kuno T, Latib A. Vascular access for transcatheter aortic valve replacement: A network meta-analysis. J Cardiol 2023; 82:227-233. [PMID: 37116649 DOI: 10.1016/j.jjcc.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/13/2023] [Accepted: 04/06/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND The choice of an alternative access for transcatheter aortic valve replacement (TAVR) remains controversial when transfemoral (TF) access is not feasible. METHODS We conducted a network meta-analysis to compare the outcomes of TAVR via various peripheral vascular accesses. MEDLINE and EMBASE were searched through July 2022 to identify studies that investigated outcomes in patients who underwent TAVR via TF, trans-subclavian (Tsc), transcarotid (TC), or transcaval (Tcav) access. A network meta-analysis was conducted via random-effects model. Outcomes of interest were major or life-threatening bleeding, stroke, major vascular complication, and 30-day mortality. RESULTS No randomized trial was identified. Our analysis included 33 observational studies that enrolled a total of 43,455 patients who underwent TAVR via TF (n = 36,202), Tsc (n = 3869), TC (n = 3066), or Tcav (n = 318) access. The risk of major or life-threatening bleeding was higher via Tsc compared with TF [odds ratio (OR); 95 % confidence interval (CI) =1.51 (1.03-2.23), p = 0.034]. The risk of stroke was higher via Tsc compared with TF and Tcav [OR (95 % CI) =2.00 (1.14-3.52), p = 0.018, OR (95 % CI) =2.43 (1.03-5.74), p = 0.044, respectively]. The risk of major vascular complications was lower via TC compared with Tsc, and Tcav and higher with Tcav compared with TF and Tsc. 30-day mortality was higher via Tsc compared with TF. Tsc was associated with higher risk of major or life-threatening bleeding compared with TF, and higher risk of stroke compared to TF and Tcav. Tcav had the highest risk of major vascular complications. CONCLUSION In patients who underwent TF, Tsc, TC, or Tcav TAVR, Tsc had a higher rate of stroke compared to TF and Tcav, and major or life-threatening bleeding compared to TF. The rate of major vascular complications in Tcav was the highest among the four approaches.
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Affiliation(s)
- Yujiro Yokoyama
- Department of Surgery, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Tomoki Sakata
- Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Takahisa Mikami
- Department of Neurology, Tufts Medical Center, Medford and Somerville, MA, USA
| | - Naoki Misumida
- Division of Cardiovascular Medicine, Gill Heart and Vascular Institute, University of Kentucky, Lexington, USA
| | - Andrea Scotti
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shimizu, Shizuoka, Japan
| | - Tadahisa Sugiura
- Department of Cardiothoracic & Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Toshiki Kuno
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Azeem Latib
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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Hoover NE, Ouranos HB, Memon S, Azemi T, Piccirillo BJ, Sadiq IR, Rizvi AA, Haider JM, Hagberg RC, Mather JF, Underhill DJ, McKay RG, Cheema M. Transcarotid Versus Transfemoral Transcatheter Aortic Valve Replacement (from a Propensity-Matched Comparison). Am J Cardiol 2022; 185:71-79. [DOI: 10.1016/j.amjcard.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/09/2022] [Accepted: 09/05/2022] [Indexed: 11/01/2022]
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Simplified TAVR Procedure: How Far Is It Possible to Go? J Clin Med 2022; 11:jcm11102793. [PMID: 35628919 PMCID: PMC9145302 DOI: 10.3390/jcm11102793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/05/2022] [Accepted: 05/12/2022] [Indexed: 02/01/2023] Open
Abstract
Increasing operators’ experience and improvement of the technique have resulted in a drastic reduction in complications following transcatheter aortic valve replacement (TAVR) in patients with lower surgical risk. In parallel, the procedure was considerably simplified, with a routine default approach including local anesthesia in the catheterization laboratory, percutaneous femoral approach, radial artery as the secondary access, prosthesis implantation without predilatation, left ventricle wire pacing and early discharge. Thus, the “simplified” TAVR adopted in most centers nowadays is a real revolution of the technique. However, simplified TAVR must be accompanied upstream by a rigorous selection of patients who can benefit from a minimalist procedure in order to guarantee its safety. The minimalist strategy must not become dogmatic and careful pre-, per- and post-procedural evaluation of patients with well-defined protocols guarantee optimal care following TAVR. This review aims to evaluate the benefits and limits of the simplified TAVR procedure in a current and future vision.
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Tsuda M, Egami Y, Nishino M, Tanouchi J. Transfemoral transcatheter aortic valve implantation in a patient with chronic type B aortic dissection. BMJ Case Rep 2022; 15:e246847. [PMID: 35039368 PMCID: PMC8768874 DOI: 10.1136/bcr-2021-246847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2021] [Indexed: 11/04/2022] Open
Abstract
A 70s woman with a history of open-heart surgery presented with severe aortic stenosis (AS). CT showed chronic type B aortic dissection (TBAD) between the distal aortic arch and the left common iliac artery. After careful consideration, we planned transfemoral (TF)-transcatheter aortic valve implantation (TAVI) using a 20-Fr long sheath to minimise number of contacts with the false lumen of the aorta. TAVI was performed under general anaesthesia, guided by transoesophageal echocardiography (TEE). A transcatheter aortic valve was successfully implanted. TEE immediately after valve implantation showed no remarkable changes in the descending thoracic aorta. Repeated postprocedural CT examinations showed no obvious changes in the aorta. The patient was stable without sequelae at the 12-month follow-up. This case demonstrates that TF-TAVI using a long sheath under TEE guidance can be a treatment option for patients with severe AS and chronic TBAD.
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Affiliation(s)
- Masaki Tsuda
- Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | | | | | - Jun Tanouchi
- Cardiology, Osaka Rosai Hospital, Sakai, Osaka, Japan
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Ranka S, Lahan S, Chhatriwalla AK, Allen KB, Chiang M, O'Neill B, Verma S, Wang DD, Lee J, Frisoli T, Eng M, Bagur R, O'Neill W, Villablanca P. Network meta-analysis comparing the short and long-term outcomes of alternative access for transcatheter aortic valve replacement. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 40:1-10. [PMID: 34972667 DOI: 10.1016/j.carrev.2021.11.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/15/2021] [Accepted: 11/29/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Several studies have pair-wise compared access sites for transcatheter aortic valve replacement (TAVR) but pooled estimate of overall comparative efficacy and safety outcomes are not well known. We sought to compare short- and long-term outcomes following various alternative access routes for TAVR. METHODS Thirty-four studies with a pooled sample size of 32,756 patients were selected by searching PubMed and Cochrane library databases from inception through 11th June 2021 for patients undergoing TAVR via 1 of 6 different access sites: Transfemoral (TF), Transaortic (TAO), Transapical (TA), Transcarotid (TC), Transaxillary/Subclavian (TSA), and Transcaval (TCV). Data were extracted to conduct a frequentist network meta-analysis with a random-effects model using TF access as a reference group. RESULTS Compared with TF, both TAO [RR 1.91, 95% CI (1.46-2.50)] and TA access [RR 2.12, 95% CI (1.84-2.46)] were associated with an increased risk of 30-day mortality. No significant difference was observed for stroke, myocardial infarction, major bleeding, conversion to open surgery, and major adverse cardiovascular or cerebrovascular events at 30 days between different accesses. Major vascular complications were lower in TA [RR 0.43, (95% CI, 0.28-0.67)] and TC [RR 0.51, 95% CI (0.35-0.73)] access compared to TF. The 1-year mortality was higher in TAO [RR of 1.35, (95% CI, 1.01-1.81)] and TA [RR 1.44, (95% CI, 1.14-1.81)] groups. CONCLUSION Non-thoracic alternative access site utilization for TAVR implantation (TC, TSA and TCV) is associated with outcomes similar to conventional TF access. Thoracic TAVR access (TAO and TA) translates into increased short and long-term mortality.
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Affiliation(s)
- Sagar Ranka
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, KS, United States
| | - Shubham Lahan
- Division of Cardiovascular Prevention & Wellness, Department of Cardiology, Houston Methodist, Houston, TX, United States
| | - Adnan K Chhatriwalla
- Department of Cardiothoracic Surgery, Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, MO, United States
| | - Keith B Allen
- Department of Cardiothoracic Surgery, Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, MO, United States
| | - Michael Chiang
- Department of Medicine, Division of Cardiology, Henry Ford Health System, Detroit, MI, United States
| | - Brian O'Neill
- Department of Medicine, Division of Cardiology, Henry Ford Health System, Detroit, MI, United States
| | - Sadhika Verma
- Department of Family Medicine, Henry Ford Allegiance Health, Jackson, MI, United States
| | - Dee Dee Wang
- Department of Medicine, Division of Cardiology, Henry Ford Health System, Detroit, MI, United States
| | - James Lee
- Department of Medicine, Division of Cardiology, Henry Ford Health System, Detroit, MI, United States
| | - Tiberio Frisoli
- Department of Medicine, Division of Cardiology, Henry Ford Health System, Detroit, MI, United States
| | - Marvin Eng
- Department of Cardiology, Banner University Medical Center, Phoenix, AZ, United States
| | - Rodrigo Bagur
- Division of Cardiology, Department of Medicine, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - William O'Neill
- Department of Medicine, Division of Cardiology, Henry Ford Health System, Detroit, MI, United States
| | - Pedro Villablanca
- Department of Medicine, Division of Cardiology, Henry Ford Health System, Detroit, MI, United States.
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Reilly JP, Parikh PB. Transcarotid transcatheter aortic valve replacement: The best alternative? Catheter Cardiovasc Interv 2021; 97:1460-1461. [PMID: 34107563 DOI: 10.1002/ccd.29761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 05/03/2021] [Indexed: 11/08/2022]
Affiliation(s)
- John P Reilly
- Division of Cardiovascular Medicine, Department of Medicine, State University of New York at Stony Brook, Stony Brook, New York, USA
| | - Puja B Parikh
- Division of Cardiovascular Medicine, Department of Medicine, State University of New York at Stony Brook, Stony Brook, New York, USA
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Lu H, Monney P, Hullin R, Fournier S, Roguelov C, Eeckhout E, Rubimbura V, Faroux L, Barrier A, Muller O, Kirsch M. Transcarotid Access Versus Transfemoral Access for Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2021; 8:687168. [PMID: 34124210 PMCID: PMC8190826 DOI: 10.3389/fcvm.2021.687168] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/12/2021] [Indexed: 01/15/2023] Open
Abstract
Background: The transfemoral (TF) route is the gold-standard access for transcatheter aortic valve replacement (TAVR). In 10–15% of patients, alternative accesses are needed, such as the transcarotid (TC) access. We performed a meta-analysis to compare 30-day mortality and complications between TC-TAVR and TF-TAVR. Methods: We searched PubMed/MEDLINE and EMBASE from inception to January 2021 to identify articles comparing TC-TAVR and TF-TAVR. Patients' baseline characteristics, procedural outcomes, and clinical 30-day outcomes were extracted. Results: We identified 9 studies, among which 2 used propensity-score matching, including 1,374 TC patients and 3,706 TF patients. TC-TAVR was associated with significantly higher EuroSCORE II and Logistic EuroSCORE values (respectively 8.0 ± 6.7 vs. 6.3 ± 5.4, p = 0.002 and 20.8 ± 14.2% vs. 20.0 ± 13.4%, p = 0.04), a higher prevalence of peripheral artery disease (52.6 vs. 32.8%, p = 0.001), previous cardiac surgery (26.3 vs. 22.4%, p = 0.008) and coronary artery disease (64.6 vs. 60.5%, p = 0.020). The pooled results found TC-TAVR to be associated with a significantly higher 30-day mortality risk (RR, 1.41, 95% CI, 1.02–1.96, p = 0.040), and a lower rate of 30-day major vascular complications (RR, 0.48, 95% CI, 0.25–0.92, p = 0.030). No significant difference was found regarding permanent pacemaker implantation, major bleeding and acute kidney injury. A subgroup analysis of the two propensity-score matched studies found a statistically increased risk of 30-day neurovascular complications (RR, 1.61, 95% CI, 1.02–2.55, p = 0.040). Conclusion: Compared with TF-TAVR, TC-TAVR was associated with an increased risk of 30-day mortality, likely related to a higher surgical risk and comorbidity burden, and with an increased risk of 30-day neurovascular complications. Careful preprocedural patient selection and close periprocedural neurological monitoring are paramount.
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Affiliation(s)
- Henri Lu
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Pierre Monney
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Roger Hullin
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Stephane Fournier
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Christian Roguelov
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Eric Eeckhout
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Vladimir Rubimbura
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Laurent Faroux
- Cardiology Department, Reims University Hospital, Reims, France
| | - Adelin Barrier
- Service of Internal Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Olivier Muller
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Matthias Kirsch
- Service of Cardiovascular Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Morozowich ST, Sell-Dottin KA, Crestanello JA, Ramakrishna H. Transcarotid Versus Transaxillary/Subclavian Transcatheter Aortic Valve Replacement (TAVR): Analysis of Outcomes. J Cardiothorac Vasc Anesth 2021; 36:1771-1776. [PMID: 34083097 DOI: 10.1053/j.jvca.2021.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/21/2021] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Steven T Morozowich
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ
| | | | | | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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