title: Alternative access for balloon-expandable transcatheter aortic valve replacement: comparison of the transaortic approach using right anterior thoracotomy to partial J-sternotomy.
abstract: OBJECTIVE
  For transcatheter aortic valve replacement (TAVR), transaortic (TAo) and transapical (TA) approaches are major alternatives in cases unsuitable for the transfemoral approach. Partial J-sternotomy is a widely used access for TAo. However, redo sternotomy or right-sided aorta may preclude this access, and right anterior thoracotomy is potentially beneficial in these cases. This study sought to evaluate the TAo approach using thoracotomy (T-TAo) and compare it to the TAo approach using a sternotomy (S-TAo) and a TA approach.
  
  
  METHODS
  In a large single-center series, consecutive TAVR patients were studied. Procedural/clinical outcomes of the T-TAo, S-TAo, and TA groups were compared up to a 30 days follow-up period.
  
  
  RESULTS
  Of 872 TAVR patients, 22 (2.5%) were T-TAo, 29 (3.3%) were S-TAo, and 86 (9.9%) were TA approaches. The TA group showed the shortest intensive care unit stay, with a median 2.0 (interquartile range 1.0-3.0) days: for T-TAo it was 3.0 (2.0-5.3) and for S-TAo, 3.0 (3.5-5.0) (P < .001). Although it was not statistically significant, the T-TAo group showed numerically less mortality (1 [4.5%], 5 [17.9%], and 8 [9.4%] in the T-TAo, S-TAo, and TA groups, respectively; P = .30), with no difference in other endpoints, including stroke/transient ischemic attack, rehospitalization, and paravalvular leak. Additionally, computed tomographic assessment revealed that T-TAo facilitated a more coaxial approach than S-TAo: 20.4° ± 8.2° versus 30.6° ± 8.2° (P < .001).
  
  
  CONCLUSIONS
  T-TAo is a feasible approach that can provide greater coaxiality. This option allows tailored and optimal access to the individual patient and facilitates a treatment strategy in nontransfemoral TAVR patients.
authors.affiliation: Cedars-Sinai Heart Institute, Los Angeles, Calif.
authors.forename: Kazuaki
authors.initials: K
authors.lastname: Okuyama
authors.affiliation: Cedars-Sinai Heart Institute, Los Angeles, Calif.
authors.forename: Hasan
authors.initials: H
authors.lastname: Jilaihawi
authors.affiliation: Cedars-Sinai Heart Institute, Los Angeles, Calif.
authors.forename: James
authors.initials: J
authors.lastname: Mirocha
authors.affiliation: Cedars-Sinai Heart Institute, Los Angeles, Calif.
authors.forename: Mamoo
authors.initials: M
authors.lastname: Nakamura
authors.affiliation: Cedars-Sinai Heart Institute, Los Angeles, Calif.
authors.forename: Danny
authors.initials: D
authors.lastname: Ramzy
authors.affiliation: Cedars-Sinai Heart Institute, Los Angeles, Calif.
authors.forename: Raj
authors.initials: R
authors.lastname: Makkar
authors.affiliation: Cedars-Sinai Heart Institute, Los Angeles, Calif. Electronic address: Wen.Cheng@cshs.org.
authors.forename: Wen
authors.initials: W
authors.lastname: Cheng
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000000981:diagnostic imaging / Q000503:physiopathology*; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D063126:Balloon Valvuloplasty / Q000009:adverse effects / Q000401:mortality; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000401:mortality; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D006801:Humans; D002546:Ischemic Attack, Transient / Q000209:etiology; D007902:Length of Stay; D015141:Los Angeles; D008297:Male; D010359:Patient Readmission; D012189:Retrospective Studies; D012307:Risk Factors; D056346:Sternotomy / Q000009:adverse effects / Q000401:mortality; D020521:Stroke / Q000209:etiology; D013907:Thoracostomy / Q000009:adverse effects / Q000401:mortality; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome