Meta-analysis supports transaortic approach in TAVI

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Hafid Armane

A meta-analysis of single-centre studies indicates that the use of the transaortic appraoch in patients undergoing transcatheter aortic valve implantation (TAVI) is associated with acceptable short-term safety and efficacy outcomes. These findings suggest, adding to previously published data, the transaortic approach can be used when the preferred transfemoral approach is not feasible.

Hafid Amrane (Department of Cardiothoracic Surgery, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands) and others report in EuroIntervention that a “transfemoral-first” approach is used in most centres, but add that an alternative approach“is advisable” if the iliac and femoral arteries are not suitable for the transfemoral approach or are too small to accommodate sheaths for valve deployment. Amrane et al explain that although the transapical approach is used as an alternative approach, “it is not preferred in patients with left ventricular function or significant frailty”. Therefore, other alternative approaches—including the transaortic approach—have been evaluated. The aim of the present study was to perform a meta-analysis of the available data for the transaortic approach.

The authors identified 16 studies (with data for 1,907 patients) that evaluated the transaortic approach. They note: “Device success according to Valve Academic Research Consortium-2 (VARC-2) among 10 studies was 91%. In 3.2%, a conversion to sternotomy was required. Major vascular complications occurred at a rate of 3.1%. Moderate or severe aortic regurgitation/paravalvular leak was reported to be 6.7%. The rate of myocardial infarction was 1%.” They add that pooled 30-day complication rates were 9.9% for mortality and 3.7% for all strokes.

According to Amrane et al, the results with transaortic TAVI are in line with results achieved with other techniques, “thus confirming that transaortic TAVI appears not to increase the risk of stroke”. “In fact, avoiding manipulation of the aortic arch and supra-aortic vessels may offer a theoretical advantage upon other retrograde TAVI accesses. Conversely, the aortic puncture required for transaortic TAVI may increase the risk of emboli and, therefore, stroke,” they comment.

Furthermore, in a subanalysis, moderate/severe paravalvular leak and aortic regurgitation were more frequent in patients receiving a Sapien valve (Edwards Lifesciences) while pacemaker implantation was higher with CoreValve (Medtronic). The authors write that previous studies, by contrast, found that CoreValve was associated with a higher rate of moderate/severe paravalvular leak and aortic regurgitation. They note: “We can only speculate that the short working distance and immediate tactile feedback achieved with transaortic TAVI made it possible for the operators to fully use the potential of the CoreValve with an increased precision of positioning, thereby maybe reducing the incidence and severity of paravalvular regurgitation in comparison to other published series.”

Concluding, Amrane et al say: “In this meta-analysis that was largely based on small single-centre experiences, transaortic TAVI appears to be a safe procedure. However, further data from larger multicentre studies are required to evaluate the optimal approach in terms of comparing transaortic with other access routes, as well as a haemisternotomy vs. thoracotomy approach.”

Armane told Cardiovascular News: “Transaortic TAVI may be good alternative in patients without suitable transfemoral access”