title: Trans-apical and trans-axillary percutaneous aortic valve implantation as alternatives to the femoral route: short- and middle-term results.
abstract: OBJECTIVE
  Trans-catheter aortic valve implantation (TAVI) is an alternative for patients not eligible for surgical aortic valve replacement. When peripheral access is not amenable by the transfemoral route (TF-TAVI), the most-used approaches are the trans-apical (TAp-TAVI) and the trans-axillary (TAx-TAVI). The aim of this study is to report the outcomes in a single-center series of consecutive patients treated by TAVI using the different approaches.
  
  
  METHODS
  From November 2007 to June 2010, 177 patients underwent TAVI by the same multispeciality valve team. TAp-TAVI was performed in the operative room, while TF-TAVI and TAx-TAVI were done in the catheterization laboratory. Follow-up was 100% complete (mean 6.0 ± 6.8 months).
  
  
  RESULTS
  TF-TAVI, TAx-TAVI, and TAp-TAVI were performed in 140 (79.1%), 19 (10.7%), and 16 patients (9.1%), respectively. The groups were not different in terms of age (p = 0.6), left ventricular ejection fraction (LVEF) (p = 0.6), Log-EuroSCORE (European System for Cardiac Operative Risk Evaluation) (p = 0.3), and Society of Thoracic Surgeons (STS) score (p = 0.7), while peripheral artery disease was higher in the TAp-TAVI and TAx-TAVI groups compared with the TF-TAVI group (p < 0.0001). The Charlson score was 10.7 ± 14.9, 5.8 ± 1.2, and 5.9 ± 1.8 for TAp-TAVI, TAx-TAVI, and TF-TAVI, respectively (p = 0.02). In-hospital (30-day) mortality was 1.4% (2/140), 12.5% (2/16), and 5.3% (1/19) for TF, Tap, and TAx, respectively (p = 0.03). At follow-up, 6 months' actuarial survival was 72.2 ± 12.0%, 67.4 ± 17.4%, and 88.4±3.1% for TAp-TAVI, TAx-TAVI, and TF-TAVI, respectively (p = 0.3).
  
  
  CONCLUSIONS
  Similar to findings from recent, larger trials, patients undergoing TF-TAVI in high-risk patients had excellent 6-month results. Although TAx-TAVI was associated with lower hospital mortality, it shared the same 6-month outcomes of TAp-TAVI, probably due to a similar selection bias.
authors.affiliation: Cardiac Surgery Department, San Raffaele Scientific Institute, Milan, Italy.
authors.forename: Maurizio
authors.initials: M
authors.lastname: Taramasso
authors.forename: Francesco
authors.initials: F
authors.lastname: Maisano
authors.forename: Micaela
authors.initials: M
authors.lastname: Cioni
authors.forename: Paolo
authors.initials: P
authors.lastname: Denti
authors.forename: Cosmo
authors.initials: C
authors.lastname: Godino
authors.forename: Matteo
authors.initials: M
authors.lastname: Montorfano
authors.forename: Antonio
authors.initials: A
authors.lastname: Colombo
authors.forename: Ottavio
authors.initials: O
authors.lastname: Alfieri
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000601:surgery*; D001365:Axilla; D006328:Cardiac Catheterization / Q000379:methods; D004812:Epidemiologic Methods; D005260:Female; D005263:Femoral Artery; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods; D016896:Treatment Outcome