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Alternative access in transcatheter aortic valve replacement-an updated focused review
Mark W Abdelnour1, Vishal Patel1, Pranav M Patel1
1Division of Cardiology, Department of Medicine, University of California Irvine Medical Center, Orange, California, CA, United States.
Insights
Transcatheter aortic valve replacement (TAVR) is the standard for severe aortic stenosis. Alternative TAVR approaches offer solutions when transfemoral access is not feasible, expanding treatment options for more patients.
Area of Science:
- Cardiology
- Interventional Cardiology
- Medical Devices
Background:
- Aortic stenosis (AS) affects a significant elderly population, with severe AS prevalence around 3.4%.
- Surgical aortic valve replacement was historically the primary treatment for severe AS.
- Transcatheter aortic valve replacement (TAVR) has emerged as the gold standard for symptomatic severe AS due to its proven safety and efficacy.
Purpose of the Study:
- To review the evolution and techniques of various transcatheter aortic valve replacement (TAVR) access methods.
- To compare the practicality and limitations of different TAVR approaches.
- To provide a foundation for case-by-case utilization and future research.
Main Methods:
- Review of transfemoral, transcarotid, transsubclavian/transaxillary, and transcaval TAVR approaches.
- Inclusion of traditional transaortic and transapical accesses.
- Consolidation of data on techniques, practicality, and limitations.
Main Results:
- Transfemoral access is preferred but not always feasible due to patient risk factors like peripheral artery disease.
- Alternative TAVR approaches are increasingly utilized when transfemoral access is contraindicated.
- The review consolidates data on diverse TAVR access routes, detailing their respective advantages and disadvantages.
Conclusions:
- Alternative TAVR access routes are crucial for expanding treatment options for patients with severe aortic stenosis.
- Understanding the nuances of each approach is vital for optimal patient selection and outcomes.
- Further research is warranted to refine techniques and expand the utility of various TAVR access methods.
Abstract:
Aortic Stenosis (AS) is a common condition with an estimated pooled prevalence of all AS in the elderly population at around 12.4%, with that of severe AS estimated to be around 3.4%. In the past, surgical aortic valve replacement was the primary treatment option for severe AS for decades. However, with the compelling evidence on the safety and efficacy of transcatheter aortic valve replacement (TAVR), it has become the gold standard treatment option for many patients with symptomatic severe AS. Transfemoral access has been the preferred method for transcatheter heart valve delivery. However, the prevalent use of TAVR on a diverse patient profile with different risk factors, such as peripheral artery disease, precluded the possibility of a transfemoral approach despite the improvement of valves and delivery systems technology. Therefore, alternative TAVR approaches have gained increasing utility in cases where transfemoral access is unfavorable. We review the journey, evolution, and techniques for different approaches of percutaneous TAVR, including transfemoral, transcarotid, transsubclavian/transaxillary, and transcaval approaches, in addition to the traditional "surgical" transaortic and transapical accesses. Consolidating these data highlights each approach's practicality and limitations, providing additional grounding for case-by-case utilization and future clinical research.
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