title: Use of transaortic, transapical, and transcarotid transcatheter aortic valve replacement in inoperable patients.
abstract: BACKGROUND
  Transcatheter aortic valve replacement (TAVR) is an effective treatment in patients with severe aortic stenosis unsuitable for surgical aortic valve replacement (SAVR). This study evaluated the early experience with the posttrial application of TAVR, with specific focus on non-transfemoral (TF) access.
  
  
  METHODS
  All patients who underwent posttrial TAVR at Emory University from November 2011 to April 2012 were reviewed. During this time, 44 posttrial TAVRs were performed: TF in 18, transapical in 11, transaortic in 12, and transcarotid in 3.
  
  
  RESULTS
  A total of 40.9% of all patients were candidates for TF implantation. Mean age was 78.2 ± 11.3 years, and 34.1% were women. Mean ejection fraction was 0.463 ± 0.164, and 90.2% had New York Heart Association class III to IV heart failure. Fifty percent were diabetic, 27.3% had moderate to severe chronic obstructive pulmonary disease, and 20.5% had a prior stroke. The mean creatinine was 1.63 ± 1.74 mg/dL, 9.1% required preoperative dialysis, and 61.4% had undergone prior cardiac operations. No patients had postoperative myocardial infarction, stroke, or required new dialysis. Intraoperative vascular complications occurred in 11.4%. No patient had more than mild perivalvular leak by transthoracic echocardiography at discharge. Mean postoperative ventilator time was 17.8 ± 40.1 hours. Intensive care unit length of stay was 58.0 ± 67.0 hours. Postoperative hospital length of stay was 6.1 ± 4.7 days. The 30-day mortality was 6.8% (3 of 44) for all patients, despite a mean The Society of Thoracic Surgeons Predicted Risk of Mortality score of 12.6.
  
  
  CONCLUSIONS
  Less than half of patients deemed appropriate for posttrial TAVR were candidates for TF implantation. The use of all available access routes leads to excellent outcomes in patients deemed inoperable.
authors: Structural Heart and Valve Center, Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia. Electronic address: vthoura@emory.edu.
authors: Vinod H
authors: VH
authors: Thourani
authors: Structural Heart and Valve Center, Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors: Rebecca L
authors: RL
authors: Gunter
authors: Structural Heart and Valve Center, Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors: Soumya
authors: S
authors: Neravetla
authors: Structural Heart and Valve Center, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors: Peter
authors: P
authors: Block
authors: Structural Heart and Valve Center, Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors: Robert A
authors: RA
authors: Guyton
authors: Division of Biostatistics, Rollins School of Public Health, Emory University School of Medicine, Atlanta, Georgia.
authors: Patrick
authors: P
authors: Kilgo
authors: Structural Heart and Valve Center, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors: Stamatios
authors: S
authors: Lerakis
authors: Structural Heart and Valve Center, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors: Chandan
authors: C
authors: Devireddy
authors: Structural Heart and Valve Center, Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors: Bradley
authors: B
authors: Leshnower
authors: Structural Heart and Valve Center, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors: Kreton
authors: K
authors: Mavromatis
authors: Structural Heart and Valve Center, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors: James
authors: J
authors: Stewart
authors: Structural Heart and Valve Center, Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors: Amy
authors: A
authors: Simone
authors: Structural Heart and Valve Center, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors: Patricia
authors: P
authors: Keegan
authors: Structural Heart and Valve Center, Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors: Tom C
authors: TC
authors: Nguyen
authors: Structural Heart and Valve Center, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors: John
authors: J
authors: Merlino
authors: Structural Heart and Valve Center, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors: Vasilis
authors: V
authors: Babaliaros
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001011:Aorta; D001024:Aortic Valve Stenosis / Q000601:surgery*; D002339:Carotid Arteries; D015331:Cohort Studies; D005260:Female; D006321:Heart; D019918:Heart Valve Prosthesis Implantation / Q000379:methods*; D006801:Humans; D008297:Male; D012189:Retrospective Studies
keywords: 28