Alternative Access Transcatheter Aortic Valve Replacement in Nonagenarians versus Younger Patients

Abstract

Background Numerous studies have documented the safety of alternatives access (AA) transcatheter aortic valve replacement (TAVR) for patients who are not candidates for transfemoral or surgical approach. There is a scarcity of studies relating use of AA TAVR in nonagenarian patients, a high-risk, frail group. Our study sought to investigate the clinical outcomes of nonagenarians who underwent AA TAVR for aortic stenosis, with comparison of nonagenarians age ≥90 years with patients age <90 years.

Methods A cohort study of 171 consecutive patients undergoing AA TAVR (transapical [TA, n = 101, 59%], transaxillary [TAX, n = 56, 33%], transaortic [TAO, n = 11, 6%], and transcarotid [TC, n = 3, 2%]) from 2012 to 2019 was analyzed. Baseline, operative, and postoperative characteristics, as well as actuarial survival outcomes, were compared.

Results AA TAVR patients had decreased aortic valve gradients with no difference detected in nonagenarians and younger patients. Operative mortality was 8% (n = 14; nine TA, three TAO, and two TAX). Compared to younger patients, significantly more nonagenarians were recorded to have new onset atrial fibrillation (7 vs. 5%, p < 0.01*). No significant difference in mortality or postoperative complications, such as stroke, pacemaker requirements, was detected. Actuarial survival at 1 and 5 years was 86 versus 87% (nonagenarians vs younger patients) and 36 versus 22%, respectively, with log-rank = 0.97.

Conclusion AA TAVR in nonagenarian patients who are not candidates for transfemoral approach can be efficaciously performed with comparable clinical outcomes to younger patients, age <90 years. Furthermore, some access sites should be avoided when possible; notably TA was associated with increased mortality, stroke, and new onset atrial fibrillation.

Keywords

outcomes; includes mortality, morbidity - aortic valve and root - heart valve - transapical - percutaneous - TAVI

Disclaimer

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

Publikationsverlauf

Eingereicht: 21. August 2019

Angenommen: 08. Februar 2020

Artikel online veröffentlicht:
06. April 2020

• References

• 1 Kayatta MO, Thourani VH, Jensen HA. et al. Outcomes for transcatheter aortic valve replacement in nonagenarians. Ann Thorac Surg 2015; 100 (04) 1261-1267 , discussion 1267
• 2 Smith CR, Leon MB, Mack MJ. et al; PARTNER Trial Investigators. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med 2011; 364 (23) 2187-2198
• 3 Biancari F, D'Errigo P, Rosato S. et al. Transcatheter aortic valve replacement in nonagenarians: early and intermediate outcome from the OBSERVANT study and meta-analysis of the literature. Heart Vessels 2017; 32 (02) 157-165
• 4 Mack MC, Szerlip M, Herbert MA. et al. Outcomes of Treatment of Nonagenarians With Severe Aortic Stenosis. Ann Thorac Surg 2015; 100 (01) 74-80
• 5 McNeely C, Zajarias A, Robbs R, Markwell S, Vassileva CM. Transcatheter aortic valve replacement outcomes in nonagenarians stratified by transfemoral and transapical approach. Ann Thorac Surg 2017; 103 (06) 1808-1814
• 6 Thourani VH, Jensen HA, Babaliaros V. et al. Outcomes in nonagenarians undergoing transcatheter aortic valve replacement in the PARTNER-I Trial. Ann Thorac Surg 2015; 100 (03) 785-792 , discussion 793
• 7 Zierer A, Wimmer-Greinecker G, Martens S, Moritz A, Doss M. The transapical approach for aortic valve implantation. J Thorac Cardiovasc Surg 2008; 136 (04) 948-953
• 8 Guyton RA, Block PC, Thourani VH, Lerakis S, Babaliaros V. Carotid artery access for transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2013; 82 (04) E583-E586
• 9 Rodés-Cabau J, Webb JG, Cheung A. et al. Transcatheter aortic valve implantation for the treatment of severe symptomatic aortic stenosis in patients at very high or prohibitive surgical risk: acute and late outcomes of the multicenter Canadian experience. J Am Coll Cardiol 2010; 55 (11) 1080-1090
• 10 Schofer N, Deuschl F, Conradi L. et al. Preferential short cut or alternative route: the transaxillary access for transcatheter aortic valve implantation. J Thorac Dis 2015; 7 (09) 1543-1547
• 11 Biasco L, Ferrari E, Pedrazzini G. et al. Access Sites for TAVI: Patient Selection Criteria, Technical Aspects, and Outcomes. Front Cardiovasc Med 2018; 5: 88
• 12 Thourani VH, Li C, Devireddy C. et al. High-risk patients with inoperative aortic stenosis: use of transapical, transaortic, and transcarotid techniques. Ann Thorac Surg 2015; 99 (03) 817-823 , discussion 823–825
• 13 Mack MJ, Brennan JM, Brindis R. et al; STS/ACC TVT Registry. Outcomes following transcatheter aortic valve replacement in the United States. JAMA 2013; 310 (19) 2069-2077
• 14 Svensson LG, Dewey T, Kapadia S. et al. United States feasibility study of transcatheter insertion of a stented aortic valve by the left ventricular apex. Ann Thorac Surg 2008; 86 (01) 46-54 , discussion 54–55
• 15 Bapat V, Khawaja MZ, Attia R. et al. Transaortic transcatheter aortic valve implantation using Edwards Sapien valve: a novel approach. Catheter Cardiovasc Interv 2012; 79 (05) 733-740
• 16 Mack MJ, Leon MB, Smith CR. et al; PARTNER 1 trial investigators. 5-year outcomes of transcatheter aortic valve replacement or surgical aortic valve replacement for high surgical risk patients with aortic stenosis (PARTNER 1): a randomised controlled trial. Lancet 2015; 385 9986 2477-2484