Alternative Access Versus Transfemoral Transcatheter Aortic Valve Replacement in Nonagenarians

Previous studies suggest that alternative access (AA) such as transapical (TA) approach to transcatheter aortic valve replacement (TAVR) is inferior to transfemoral (TF) approach. However, there is a paucity of data characterizing these outcomes, and studies often do not consider transaortic (TAO) and transaxillary (TAX) TAVR approaches. Therefore, the purpose of this study was to compare the outcomes of nonagenarians undergoing AA-TAVR compared to TF-TAVR.

A concurrent cohort study of 148 consecutive nonagenarian patients (≥90 years old) undergoing TAVR from April 2012 to July 2017 was carried out. We stratified the patient cohort into two groups based on access approach: TF-TAVR (n = 112); and AA-TAVR (n = 36), which included TA (n = 24), TAX (n = 8), and TAO (n = 4) approaches. Preoperative, operative, and postoperative outcomes and 5-year actuarial survival rates were analyzed.

Compared to TF-TAVR, patients undergoing AA-TAVR were more likely to require blood transfusions (28% vs 69%; P<.001) and readmission (16% vs 58%; P<.001). AA-TAVR also resulted in significantly higher rates of postoperative complications, such as stroke (1% vs 8%; P=.02) and atrial fibrillation (19% vs 36%; P=.03). There was no significant difference in aortic valve gradients (P>.05), operative mortality rate (6% vs 8%; P=.66), or actuarial 5-year survival rate (68% vs 44%, log-rank P=.10).

There is a higher risk of adverse events following AA-TAVR compared with TF-TAVR. Therefore, TF-TAVR is recommended when feasible, with AA approach as a viable back-up option in nonagenarians.