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Identifying Patients without a Survival Benefit following Transfemoral and Transapical Transcatheter Aortic Valve Replacement.

ABSTRACT: Transcatheter aortic valve replacement (TAVR) offers a novel treatment option for patients with severe symptomatic aortic valve stenosis, particularly for patients who are unsuitable candidates for surgical intervention. However, high therapeutical costs, socio-economic considerations, and numerous comorbidities make it necessary to target and allocate available resources efficiently. In the present study, we aimed to identify risk factors associated with futile treatment following transfemoral (TF) and transapical (TA) TAVR. Five hundred and thirty-two consecutive patients (82 ± 9 years, female 63%) who underwent TAVR between June 2009 and December 2016 at the Vienna Heart Center Hietzing were retrospectively analyzed to identify predictors of futility, defined as all-cause mortality at one year following the procedure for the overall patient cohort, as well as the TF and TA cohort. Out of 532 patients, 91 (17%) did not survive the first year after TAVR. A multivariate logistic model identified cerebrovascular disease, home oxygen dependency, wheelchair dependency, periinterventional myocardial infarction, and postinterventional renal replacement therapy as the factors independently associated with an increased one-year mortality. Our findings underscore the significance of a precise preinterventional evaluation, as well as illustrating the subtle differences in baseline characteristics in the TF and TA cohort and their impact on one-year mortality.

SUBMITTER: Geisler D

PROVIDER: S-EPMC8584860 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Dose approach matter? A meta-analysis of outcomes following transfemoral versus transapical transcatheter aortic valve replacement.

Project description:BackgroundTranscatheter aortic valve replacement (TAVR) has gained increasing acceptance for patients with aortic disease. Both transfemoral (TF-TAVR) and transapical (TA-TAVR) approach were widely adopted while their performances are limited to a few studies with controversial results. This meta-analysis aimed to compare the mortality and morbidity of complications between TF- versus TA-TAVR based on the latest data.MethodsElectronic databases were searched until April 2021. RCTs and observational studies comparing the outcomes between TF-TAVR versus TA-TAVR patients were included. Heterogeneity assumption was assessed by an I2 test. The pooled odds ratios(OR) or mean differences with corresponding 95% confidence intervals (CI) were used to evaluate the difference for each end point using a fixed-effect model or random-effect model based on I2 test.ResultsThe meta-analysis included 1 RCT and 20 observational studies, enrolling 19,520 patients (TF-TAVR, n = 11,986 and TA-TAVR, n = 7,534). Compared with TA-TAVR, TF-TAVR patients showed significantly lower rate of postoperative in-hospital death (OR = 0.67, 95% CI 0.59-0.77, P < 0.001) and 1-year death (OR = 0.53, 95% CI 0.41-0.69, P < 0.001). Incidence of major bleeding and acute kidney injury were lower and length of hospital stay was shorter, whereas those of permanent pacemaker and major vascular complication were higher in TF-TAVR patients. There were no significant differences between TF-TAVR versus TA-TAVR for stroke and mid-term mortality.ConclusionsThere were fewer early deaths in patients with transfemoral approach, whereas the number of mid-term deaths and stroke was not significantly different between two approaches. TF-TAVR was associated with lower risk of bleeding, acute kidney injury as well as shorter in-hospital stay, but higher incidence of vascular complication and permanent pacemaker implantation.

| S-EPMC8320184 | biostudies-literature

Comparative Outcomes of Transapical Versus Transfemoral Access for Transcatheter Aortic Valve Replacement in Diabetics.

Project description:IntroductionThe outcomes of transfemoral (TF) compared with transapical (TA) access for transcatheter aortic valve replacement (TAVR) in diabetics are unknown.MethodsWe queried the NIS database (2011-2014) to identify diabetics who underwent TAVR. We performed a propensity matching analysis comparing TF-TAVR versus TA-TAVR.ResultsThe analysis included 14.555 diabetics who underwent TAVR. After matching, in-hospital mortality was not different between TF-TAVR and TA-TAVR. (3.5 vs. 4.4%, p = 0.11). TF-TAVR was associated with lower rates of cardiogenic shock (2.7 vs. 4.7%, p = 0.02), use of mechanical circulatory support (2.0 vs. 2.9%, p = 0.03), acute renal failure (17.8 vs. 26.5%, p < 0.001), major bleeding (35.8 vs. 40.7%, p < 0.001) and respiratory complications (1.1 vs. 4.4%, p < 0.001) compared with TA-TAVR. However, TF-TAVR was associated with a higher rate of vascular complications (2.9 vs. 0.9%, p < 0.001), cardiac tamponade (0.5 vs. 0.0%, p < 0.001), complete heart block (10.8 vs. 7.7%, p < 0.001) and pacemaker insertion (11.8 vs. 8.3%, p < 0.001). There was no difference between both groups in acute stroke (1.8 vs. 2.2%, p = 0.39), hemodialysis (2.0 vs. 2.2%, p = 0.71), and ventricular arrhythmias (4.9 vs. 4.2%, p = 0.19). Notably, TF-TAVR was associated with higher mortality, acute stroke, AKI, hemodialysis, PCI, and respiratory complications in complicated diabetics compared with non-complicated diabetics.ConclusionsThis observational analysis showed no difference in-hospital mortality between TF-TAVR and TA-TAVR among diabetic patients. Studies exploring the optimal access for TAVR among diabetics are recommended.

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Transapical versus transfemoral approach and risk of acute kidney injury following transcatheter aortic valve replacement: a propensity-adjusted analysis.

Project description:BackgroundThe aim of this study was to compare the incidence of post-procedural acute kidney injury (AKI) and other renal outcomes in patients undergoing transapical (TA) and transfemoral (TF) approaches for transcatheter aortic valve replacement (TAVR).MethodsAll consecutive adult patients undergoing TAVR for aortic stenosis from 1 January 2008 to 30 June 2014 at a tertiary referral hospital were included. AKI was defined based on Kidney Disease Improving Global Outcomes (KDIGO) criteria. Logistic regression adjustment, propensity score stratification, and propensity matching were performed to assess the independent association between procedural approach and AKI.ResultsOf 366 included patients, 171 (47%) underwent TAVR via a TA approach. AKI occurrence in this group was significantly higher compared to the TF group (38% vs. 18%, p?<?.01). The TA approach remained significantly associated with increased risk of AKI after logistic regression (OR 3.20; CI 1.68-4.36) and propensity score adjustment: OR 2.83 (CI 1.66-4.80) for stratification and 3.82 (CI 2.04-7.44) for matching. Nonetheless, there was no statistically significant difference among the TA and TF groups with respect to major adverse kidney events (MAKE) or estimated glomerular filtration rate (eGFR) at six months post-procedure.ConclusionIn a cohort of patients undergoing TAVR for aortic stenosis, a TA approach significantly increases the AKI risk compared with a TF approach. However, the TAVR approach did not affect severe renal outcomes or long-term renal function.

| S-EPMC6014512 | biostudies-literature

The risk of acute kidney injury following transapical versus transfemoral transcatheter aortic valve replacement: a systematic review and meta-analysis.

Project description:BackgroundThe aim of this systematic review is to examine the literature for the risk of acute kidney injury (AKI) in patients who underwent transcatheter aortic valve replacement (TAVR) based on transapical (TA) versus transfemoral (TF) approaches.MethodsA literature search was conducted utilizing Embase, Medline, Cochrane Database of Systematic Reviews and ClinicalTrials.gov from inception through December 2015. Studies that reported relative risk, odds ratio or hazard ratio comparing the AKI risk in patients who underwent TA-TAVR versus TF-TAVR were included. Pooled risk ratio (RR) and 95% confidence interval (CI) were calculated using a random effect, generic inverse variance method.ResultsSeventeen cohort studies with 5085 patients were enrolled in the analysis to assess the risk of AKI in patients undergoing TA-TAVR versus TF-TAVR. The pooled RR of AKI in patients who underwent TA-TAVR was 2.26 (95% CI 1.79-2.86) when compared with TF-TAVR. When meta-analysis was confined to the studies with adjusted analysis for confounders evaluating the risk of AKI following TAVR, the pooled RR of TA-TAVR was 2.89 (95% CI 2.12-3.94). The risk for moderate to severe AKI [RR 1.02 (95% CI 0.57-1.80)] in patients who underwent TA-TAVR compared with TF-TAVR was not significantly higher.ConclusionsOur meta-analysis demonstrates an association between TA-TAVR and a higher risk of AKI. Future studies are required to assess the risks of moderate to severe AKI and mortality following TA-TAVR versus TF-TAVR.

| S-EPMC4957730 | biostudies-literature

In-hospital outcomes comparison of transfemoral vs transapical transcatheter aortic valve replacement in propensity-matched cohorts with severe aortic stenosis.

Project description:BackgroundTranscatheter aortic valve replacement (TAVR) is the preferred option for high-risk patients with severe aortic stenosis. The preferred access for TAVR is transfemoral (TF). Alternatives include the transapical (TA), trans-subclavian (TS), and direct aortic (TAo) approaches.HypothesisThe TF approach is associated with lower in-hospital outcomes as well as shorter length of stay and lower cost of hospitalization.MethodsThe National Inpatient Sample database from 2012 through 2014 was used to obtain the TAVR study population. International Classification of Diseases, 9th Revision, Clinical Modification procedure codes were utilized to identify the 2 groups. In-hospital outcomes were compared in propensity-score-matched (1:3) cohorts, in which we took TA-TAVR as a control.ResultsA total of 8210 (weighted N = 41 050) patients were identified. Of these, 1622 (weighted N = 8110) patients underwent TA-TAVR and 6588 (weighted N = 32 940) patients underwent TF-TAVR. In-hospital mortality was lower with TF-TAVR (4% vs 5.4%; P = 0.0355), along with a shorter length of stay (7.7 vs 9.7 days; P < 0.0001) and lower median hospitalization cost ($64 216 vs $74 735; P < 0.0001). Secondary outcomes of acute renal failure, transfusion, cardiogenic shock, and composite of all complications were lower with TF-TAVR.ConclusionsTF-TAVR is safer and associated with lower in-hospital outcomes compared with TA-TAVR and should be the preferred approach. As TAVR is gaining popularity in intermediate- and low-risk patients, we must not lose sight of the serious mortality and secondary outcomes associated with TA-TAVR access.

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Transfemoral versus transcarotid access for transcatheter aortic valve replacement.

Project description:ObjectivesTo compare the outcomes after transcatheter aortic valve replacement (TAVR) through a transfemoral (TF) and transcarotid (TC) access at our institution.MethodsFrom January 2014 to January 2020, 62 TC-TAVR and 449 TF-TAVR were performed using 2 prosthesis devices (Edwards SAPIEN 3, n = 369; Medtronic Evolut R, n = 142). Propensity score matching was used to adjust for imbalance in the baseline characteristics of the study groups.ResultsPropensity score matching provided 62 matched pairs with comparable operative risk (mean European System for Cardiac Operative Risk Evaluation II, TC-TAVR 7.6% vs TF-TAVR 6.6%, P = .17). Thirty-day mortality (4.8% vs 3.2%, P = 1.00) and 2-year mortality (11.3% vs 12.9%, P = .64) after TC-TAVR were comparable with TF-TAVR. Strokes were numerically more frequent after TC-TAVR compared with TF-TAVR (3.2% vs 0%, P = .23), but the difference did not reach statistical significance. TF-TAVR was associated with a significantly greater risk of permanent pacemaker implantation (29.0% vs 12.9%, P = .04) compared with TC-TAVR. Other complications were not frequent and were similarly distributed between the matched groups.ConclusionsTC access for TAVR was associated with satisfactory results compared to the femoral access. TC-TAVR could be considered a valid and safe alternative to TF-TAVR when femoral access is contraindicated.

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Operator Radiation Exposure During Transfemoral Transcatheter Aortic Valve Replacement.

Project description:BackgroundThe level of radiation exposure received by operators performing transcatheter aortic valve replacement (TAVR) is not well investigated. The aim of this study is to measure the amount of radiation received by operators performing transfemoral TAVR and to identify various patient and procedural characteristics associated with increased radiation exposure.MethodsPrimary (operator 1) and secondary (operator 2) operators' equivalent radiation doses in micro Sieverts (µSv) were calculated prospectively using real-time radiation dosimeters for a total of 140 consecutive transfemoral TAVRs. Corresponding eye and thorax radiation exposures between the operators were compared. Associations between various patient and procedural characteristics and the radiation exposure were tested using the t-test and Wilcoxon Mann-Whitney rank-sum test with Monte Carlo estimation. Multivariable regression analysis was also conducted.ResultsOperator 1 had significantly higher cumulative equivalent radiation exposure than operator 2 (86 µSv vs 38 µSv, p-value: <0.0001) which was consistent at the level of the thorax (67 µSv vs 22 µSv, p-value: <0.0001), but not at the level of the eye (16.5 µSv vs 15 µSv, p-value: 0.30). On multivariable analysis, patient obesity and intraprocedural complications were associated with higher radiation exposure to both operators. Ad hoc percutaneous coronary intervention led to excessive radiation exposure to the secondary operator.ConclusionsTransfemoral TAVR is associated with a modest amount of radiation exposure to operators and is significantly higher for the primary operator than for the secondary operator.

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Synchronous Type 3 EVAR Endoleaks at Multiple Sites Following Transfemoral Transcatheter Aortic Valve Replacement

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Delayed left main coronary obstruction following transfemoral inovare transcatheter aortic valve replacement: A challenging case.

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Project description: Not available

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