Transfemoral versus transapical approach for transcatheter aortic valve implantation: a systematic review and meta-analysis of adjusted studies

Background

In selected patients with severe aortic stenosis, transcatheter aortic valve implantation (TAVI), via either transfemoral (TF) or transapical (TA) access, offers a less invasive alternative to standard surgical replacement. Comparison of TF- vs. TA-TAVI is usually confounded by the higher comorbidities of patients undergoing TA-TAVI, rendering the observed comparison of the TF- vs. TA-approach unclear. The present meta-analysis provides updated evidence of this comparison by focusing on studies reporting adjusted outcomes.

Methods

A systematic review of the literature was performed in MEDLINE, EMBASE, Web of Science, clinicaltrials.gov, and Cochrane database. We only included studies in which the comparison between TF- and TA-TAVI was adjusted for potential confounders. Primary outcomes were early and mid-term mortality. Secondary outcomes included cardiovascular events, bleeding, pacemaker, and acute kidney injury. Survival data was either obtained directly from reported outcomes or estimated from Kaplan-Meier curves. Meta-regression was used to adjust for follow-up duration. Meta-analyses were performed using random effects models on odds ratios (OR) and hazard ratios (HR). The protocol was registered on PROSPERO (ID: CRD42020218163).

Results

A total of 24 studies with 36,158 patients were included in the present analyses. Of these studies, 7 used propensity score adjustment techniques and 17 used multivariable regression. TA-TAVI was associated with significantly higher postoperative mortality at 30 days (OR=1.67; 95% CI, 1.34 to 2.09; p<0.001) and 1 year (HR, 1.36; 95% CI, 1.21 to 1.53; p<0.001). However, meta-analysis of studies censoring patients who died in the first 30 days showed no significant difference in 1 year mortality by access route (HR, 1.20; 95% CI, 0.95 to 1.52; p=0.13). TA-approach was associated with increased perioperative surgical complications, such as bleeding (OR, 1.46, 95% CI, 1.09 to 1.96; p=0.012), acute kidney injury (OR, 2.31, 95% CI 1.60 to 3.33; p=0.001), and myocardial infarction (OR, 1.83, 95% CI 1.06 to 3.16; p=0.029). TA-TAVI was associated with reduced vascular complications (OR, 0.32, 95% CI 0.18–0.56; p<0.001), late postoperative aortic regurgitation (OR, 0.48, 95% CI 0.30 to 0.75; p=0.001), and a trend towards less pacemaker requirement (OR, 0.80, 95% CI 0.60–1.08, p=0.15).

Conclusions

Based on this meta-analysis of adjusted studies, a TA approach is associated with higher early and mid-term mortality compared to TF-TAVI. Excess mortality is likely driven by higher perioperative bleeding, renal complications and myocardial infarction. TA-TAVI did confer some benefits, such as reduced vascular complications, late postoperative aortic regurgitation, and a trend towards less pacemaker requirement. The optimal TAVI route should be based on individualized assessment by a multidisciplinary team. Longer follow-up and randomized studies are needed to ascertain long-term outcomes.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

[Radial artery occlusion ofter coronarography: is it really a problem?]

The use of transradial access for cardiac procedures has increased worldwide over the past two decades. Despite the many advantages this technique offers, there remains some concern that radial artery occlusion, a potential complication of radial cannulation, might lead to significant ischemic sequelae in the hand. This paper reviews the major causes, its possible consequences and the strategies for its prevention and treatment. It appears however from multiple studies that there is little or no correlation between radial occlusion and symptomatic hand ischemia.

Short and long-term outcomes of alcohol septal ablation with the trans-radial versus the trans-femoral approach: A single center-experience

BACKGROUND

Although the trans-radial approach (TR) has been applied to various subsets of patients in percutaneous coronary intervention, the feasibility, efficacy, acute procedural and long-term outcomes of TR versus trans-femoral approach (TF) for alcohol septal ablation (ASA) have not yet been determined.

OBJECTIVES

The aim of this study was to compare the short and long-term outcomes of ASA with the TR approach compared to the TF approach.

METHODS

We retrospectively analyzed 240 patients who underwent an ASA procedure at our institution from November 1999 to November 2015. The TR approach was performed in 172 cases and the TF approach in the remaining 68 cases.

RESULTS

The use of TR approach progressively increased from 62% in 1999-2005 to 91% in 2011-2015 (p=0.0001). The TF and TR group had similar age, baseline NYHA class (NYHA 3 or 4) and mean left ventricular outflow tract peak gradient before ASA. Total contrast used (TR: 73.2±47.2ml; TF: 88.7±49.3ml, p=0.11), total radiation Air kerma area product (TR: 43.7±48.0Gycm(-2); TF: 55.9±48.2Gycm(-2); p=0.39) and peak left ventricular outflow tract gradient immediately after ASA (TR: 19.1±19.6mmHg; TF: 20.4±18.0mmHg, p=0.63) were similar in both groups. Procedural success was 91.9% and 91.2% in the TR and TF groups, respectively (p=0.53). At 30days, there was 2 intra-hospital death (1 in TF and 1 in TR), 1 major stroke in the TF group and 1 coronary artery dissection in the TR group. Vascular complications were less frequent in the TR group (0.58% vs. 7.3%; p=0.002). The mean length of follow-up was 4.56±4.34years (IQR 0.69-8.2; median 2.92years; maximum: 15.5years). By Kaplan-Meier estimate, the observed survival in the overall cohort was comparable to the expected survival for a sex and age-matched comparable general French population at 10years (86.9 vs. 83.6%, p=0.88). Survival was similar between the TR and TF group (92.1% vs. 89.7% at 6years, respectively; p=0.71).

CONCLUSIONS

Alcohol septal ablation from the radial approach can be performed with similar acute and long-term success, but with lower vascular complications compared to the femoral approach.

[Platypnea-orthodeoxia revealed by recurrent syncope episodes]

Platypnea-orthodeoxia is a rare clinical condition which must be examined as a differential diagnosis for any bout of faintness occurring during standing or dyspnea that is exacerbated by standing. This syndrome is often associated with a patent foramen ovale. Its physiopathology is not univocal and the association of many anatomical criteria seems to be mandatory. Contrast echocardiography confirms diagnosis and closure of the patent foramen ovale during interventional catheterization and is currently the therapeutic method of choice. After closure of the foramen ovale, clinical improvement is spectacular and durable.

Direct phase determination for the molecular envelope of tryptophanyl-tRNA synthetase from Bacillus stearothermophilus by X-ray contrast variation

Monoclinic crystals of Bacillus stearothermophilus tryptophanyl-tRNA synthetase grown in the presence of substrate tryptophan (space group P2(1)) display evidence of a low-resolution trigonal space group (P321). The origin and averaging transformations for the local 32 point group of this unusually clear sixfold non-crystallographic symmetry may be inferred without prior estimation of the electron density. This local symmetry was exploited in conjunction with solvent density contrast variation to determine the shape of the molecular envelope. X-ray intensities measured from crystals equilibrated in mother liquors of three different electron densities were used to estimate three parameters for each reflection: the modulus of the envelope transform, [Gh]; and components, Xh and Yh, relative to Gh, of the structure-factor vector for the transform of intramolecular density fluctuations. The moduli ([Gh]) behave somewhat like structure-factor amplitudes from small-molecule crystals, and estimation of their unknown phases was successfully carried out by statistical direct methods. Reflections to 18 A resolution, which obey rather well the symmetry of space group P321, were merged to produce an asymmetric unit in that space group. [Gh] values for the 34 strongest of these were phased using the small-molecule direct-methods package MITHRIL [Gilmore (1984). J. Appl Cryst. 17, 42-46]. The best phase set was expanded back to the P2(1) lattice and negative density was truncated to generate initial phases for all reflections to 18 A resolution. Phase refinement by iterative imposition of the local 32 symmetry produced an envelope with convincing features consistent with known properties of the enzyme. The envelope implies that the tryptophanyl-tRNA synthetase dimer is an elongated structure with an axial ratio of about 4:1, in which the monomers have two distinct domains of unequal size. The smaller of these occurs at the dimer interface, and resembles the nucleotide binding portion of the tyrosyl-tRNA synthetase. It may therefore contain the amino-terminal one hundred or so residues, including all three cysteines, previously suggested to comprise a nucleotide-binding domain in the tryptophanyl enzyme. A purely crystallographic test of the overall features of this envelope was carried out by transporting it to a tetragonal crystal form of the same protein in which the asymmetric unit is a monomer. The small domain fits snugly inside three mercury and one gold heavy-atom binding sites for this crystal form; and symmetry-related molecules provide excellent, but very different, lattice contacts in nearly all directions.

RSPACE – a reciprocal-space modelling tool

RSPACE is an interactive computer-graphics program that models the relationship between crystallographic data-collection hardware and reciprocal space. It is designed to help crystallographers plan efficient complex data-collection strategies for area detector systems, and as an educational tool. Because RSPACE models the interaction of crystal, detector and goniostat geometry in a general way, it is of particular interest to users of area detectors interfaced with multi-axis goniostats.