title: High-risk patients with inoperative aortic stenosis: use of transapical, transaortic, and transcarotid techniques.
abstract: BACKGROUND
  Patient characteristics and procedural outcomes from nontransfemoral (non-TF) transcatheter aortic valve replacement (TAVR) in high-risk or inoperable patients with aortic stenosis have been incompletely reported. The purpose of this study was to compare outcomes with non-TF TAVR access techniques including transapical (TA), transaortic (TAo), and transcarotid (TC) TAVR with a balloon-expandable valve.
  
  
  METHODS
  A retrospective review was performed of all patients undergoing TA, TAo, and TC TAVR from 2007 to 2013 at Emory University. Preoperative risk factors and postoperative outcomes were evaluated using Valve Academic Research Consortium-2 definitions.
  
  
  RESULTS
  Of 469 patients undergoing TAVR during that period at our institution, 139 underwent TA TAVR, 35 had Tao TAVR, and 11 had TC TAVR. Patients undergoing TC TAVR were younger than those undergoing TA TAVR and TAo TAVR (mean ages: TC, 68.9 ± 23.6 years; TA, 81.3 ± 7.7 years; Tao, 83.8 ± 8.3 years; p = 0.017). Most patients undergoing TAo TAVR were women (82.9%), whereas patients undergoing TA TAVR were more likely to be men (62.6%). Slightly more than half of patients undergoing TA TAVR (54.7%) and TC (54.6%) TAVR had undergone previous coronary artery bypass grafting (CABG), whereas no patients underwent TAo TAVR (0%). There was no preoperative difference in ejection fraction, New York Heart Association classification, significant chronic obstructive pulmonary disease, and The Society of Thoracic Surgeons predicted risk of mortality between TA TAVR, Tao TAVR, and TC TAVR, respectively. Average postoperative length of stay was 9 to 11 days and was similar among groups (p = 0.22). There were 13 (9.4%) TA TAVR operative deaths and 4 (11.4%) operative deaths in the TAo TAVR group. There were no deaths in the TC TAVR group.
  
  
  CONCLUSIONS
  In high-risk and inoperable patients who are not candidates for TF TAVR, careful selection of alternative access options can lead to excellent and comparable postoperative outcomes.
authors.affiliation: 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.forename: Vinod H
authors.initials: VH
authors.lastname: Thourani
authors.affiliation: Structural Heart and Valve Center, Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Chun
authors.initials: C
authors.lastname: Li
authors.affiliation: Structural Heart and Valve Center, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Chandan
authors.initials: C
authors.lastname: Devireddy
authors.affiliation: Structural Heart and Valve Center, Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Hanna A
authors.initials: HA
authors.lastname: Jensen
authors.affiliation: Department of Biostatistics, Emory University Rollins School of Public Health, Emory University, Atlanta, Georgia.
authors.forename: Patrick
authors.initials: P
authors.lastname: Kilgo
authors.affiliation: Structural Heart and Valve Center, Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Bradley G
authors.initials: BG
authors.lastname: Leshnower
authors.affiliation: Structural Heart and Valve Center, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Kreton
authors.initials: K
authors.lastname: Mavromatis
authors.affiliation: Structural Heart and Valve Center, Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Eric L
authors.initials: EL
authors.lastname: Sarin
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School Houston, Memorial Hermann Hospital-Heart and Vascular Institute, Houston, Texas.
authors.forename: Tom C
authors.initials: TC
authors.lastname: Nguyen
authors.affiliation: Structural Heart and Valve Center, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Mihir
authors.initials: M
authors.lastname: Kanitkar
authors.affiliation: Structural Heart and Valve Center, Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Guyton
authors.affiliation: Structural Heart and Valve Center, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Peter C
authors.initials: PC
authors.lastname: Block
authors.affiliation: Structural Heart and Valve Center, Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Amanda L
authors.initials: AL
authors.lastname: Maas
authors.affiliation: Structural Heart and Valve Center, Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Amy
authors.initials: A
authors.lastname: Simone
authors.affiliation: Structural Heart and Valve Center, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Patricia
authors.initials: P
authors.lastname: Keegan
authors.affiliation: Structural Heart and Valve Center, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: John
authors.initials: J
authors.lastname: Merlino
authors.affiliation: Structural Heart and Valve Center, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: James P
authors.initials: JP
authors.lastname: Stewart
authors.affiliation: Structural Heart and Valve Center, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Stamatios
authors.initials: S
authors.lastname: Lerakis
authors.affiliation: Structural Heart and Valve Center, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
authors.forename: Vasilis
authors.initials: V
authors.lastname: Babaliaros
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001013:Aorta, Thoracic; D001024:Aortic Valve Stenosis / Q000601:surgery*; D017536:Carotid Artery, Common; D005260:Female; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D018570:Risk Assessment; D065467:Transcatheter Aortic Valve Replacement / Q000379:methods*; D016896:Treatment Outcome