Trends and Outcomes of Alternative-Access Transcatheter Aortic Valve Replacement

Alternative access (AA) is still required for a significant proportion of patients undergoing transcatheter aortic valve replacement (TAVR). We sought to compare the clinical outcomes of patients undergoing AA vs transfemoral (TF) access.

We retrospectively evaluated the outcomes of patients undergoing AA-TAVR between April 2011 and November 2016, and compared them with those who had TF-TAVR. Chi-square and Mann-Whitney U-tests were used to compare the groups and Kaplan-Meier analysis was performed to estimate long-term survival.

TAVR was performed in a total of 600 patients, of which 78 (13%) had AA and 522 (87%) had TF access. Patients undergoing AA were younger, and had higher prevalence of chronic obstructive pulmonary disease, peripheral vascular disease, prior myocardial infarction, and prior sternotomy. Greater than mild paravalvular regurgitation (4.2% vs 0.0%; P=.04) and unplanned vascular surgery (5.4% vs 1.3%; P=.09) were more frequent in the TF group. However, patients who underwent AA had longer hospital stay (median 4 days [interquartile range, 3-7 days] vs 3 days [interquartile range, 3-4 days]; P<.001) and an increased incidence of prolonged ventilation (5.1% vs 1.3%; P=.06), 30-day all-cause (5.1% vs 1.7%; P=.08), and cardiovascular mortality (5.1% vs 1.3%; P=.04). The 6-month (15.7% vs 5.7%; P<.01) and 12-month (16.7% vs 10.2%; P=.07) mortality rates were higher for patients undergoing AA. The usage of AA significantly decreased over time (P=.01), primarily driven by a decrease in transapical (P<.001) and direct aortic access (P=.02).

AA-TAVR is associated with an increased incidence of postoperative adverse events, including mortality, when compared with those undergoing TF access.