Gerhard Schymik (Medical Clinic IV-Municipal Hospital Karlsruhe, Karlsruhe, Germany) and others report in Circulation: Cardiovascular Interventions that at a centre with an experienced multidisciplinary heart team, transapical transcatheter aortic valve implantation (TAVI) can be performed with comparable results to transfemoral TAVI.
The authors note that there is a “common perception” that transapical TAVI is associated with higher long-term mortality than is transfemoral TAVI and that registry data indicate that the transapcial route is associated with worse 30-day mortality. The aim of their study was to review access-related complications and survival using propensity score matching in patients undergoing either transapical or transfemoral TAVI at their high-volume centre.
Between May 2008 and April 2012, 1,000 inoperable or high-risk patients underwent TAVI at the centre. Of these, 413 underwent the transapical route (403 receiving Edwards Lifesciences’ Sapien/Sapien XT valves and 11 receiving Symetis’ Acurate TA valve) and 587 underwent the transfemoral route (399 receiving Sapien/Sapien XT valves and 188 receiving Medtronic’s CoreValve).The decision, made by a multidisciplinary heart team, to use the transapcial or transfemoral route was based on the patient’s characteristics (eg. diameter of the peripheral vessels) or the availability of the valves—neither route was seen as the preferred choice. The primary objective was the 30-day and long-term mortality, with the second objective being the rate of 30-day complications using the Valve Academic Research Consortium (VARC) endpoint definitions version II.
At 30 days, in the full cohort, survival probability was significantly lower for patients who underwent transapical access compared with those underwent transfemoral access. However this difference in long-term mortality risk was not significant in the propensity score matched cohort (708 patients overall; p=0.17 for the difference between groups), which Schymik et al state indicates that the difference in the full cohort “may be based on the risk profile of transapical patients compared with that of the transfemoral TAVI patients” rather than the access route itself. Furthermore, at 30 days, there were no significant differences in the rate of fatal cardiovascular events, non-fatal cardiovascular events, periprocedural myocardial infarction, and stroke/transient ischaemic attack between groups in either the full cohort or in the propensity score matched cohort.
However, in both cohorts, the transapical access route was associated with a significantly higher rate of stage one renal complications (31.1% vs. 13.8% for transfemoral; p<0.0001) in the propensity score matched cohort) while the transfemoral route was associated with significantly more major vascular complications (15.8% vs. 2.5% for the transapical route; p<0.0001).
The authors comment about the overall findings: “The results are in partial disagreement with earlier registry results, although it enforces other analyses. It seems reasonable to assume that this result can be attributed to the experience of this single high TAVI volume centre with a transapical mortality that is less than in many other registries.” They conclude: “Short- and long-term mortality between transapcial and transfemoral TAVI can be reduced in an experienced heart team and procedural considerations may guide treatment decisions and influence complication rates.”