Access Site and Pacemaker Outcomes After TAVR in HFrEF Patients: Axillary vs Femoral Approach

Aortic stenosis is a prevalent disease affecting approximately 10% of the population by the eighth decade, it is a fatal disease without treatment, with an annual mortality rate reaching 25%. Valve replacement, either through surgical or transcatheter approach, is the only therapeutic option. Over the last 15 years, the indications for transcatheter aortic valve replacement (TAVR) have spread to include young and low surgical risk patients.

Our study aims to address this gap in the literature by comparing the adverse outcome after TAVR through axillary versus femoral access in heart failure reduce ejection fraction (HFrEF) patients who underwent TAVR within 30 days of the procedure.

We used data from TriNetX US collaborative network database, including HFrEF patients who had TAVR through axillary or femoral access between 2015 and 2025. Propensity score matching was done to minimize the difference in baseline characteristics between the two cohorts. Outcomes were observed within the first 30 days of TAVR.

A total of 206 patients in each cohort (axillary vs. femoral) were studied after propensity score matching. The incidence of permanent pacemaker (PPM) insertion was comparable between groups (5.0% vs. 5.1%; OR: 0.984, 95% CI: 0.400-2.419; HR: 0.365, 95% CI: 0.097-1.376; p = 0.157). Secondary outcomes showed no significant differences between the axillary and femoral approaches, including major vascular complications (OR: 0.542, 95% CI: 0.238-1.231; HR: 0.448, 95% CI: 0.192-1.046), acute kidney injury (OR: 0.922, 95% CI: 0.430-1.976; HR: 0.940, 95% CI: 0.459-1.922), all-cause mortality (OR: 1.010, 95% CI: 0.411-2.482; HR: 1.040, 95% CI: 0.433-2.498), cerebrovascular accident (OR: 0.980, 95% CI: 0.390-2.460; HR: 1.142, 95% CI: 0.384-3.399), and acute coronary syndrome (OR: 0.885, 95% CI: 0.355-2.208; HR: 1.211, 95% CI: 0.271-5.412).

Our study finding showed no difference in the permanent pacemaker insertion or secondary outcomes (Major vascular complications, Acute Kidney Injury, Cerebrovascular accident, Acute coronary syndrome, and All-cause mortality) within the first 30 days of TAVR in patients with HFrEF, whether the access axillary or femoral.