title: Transapical and Transaortic Transcatheter Aortic Valve Replacement in the United States.
abstract: BACKGROUND
  When transcatheter aortic valve replacement (TAVR) cannot be carried out through transfemoral access, alternative access TAVR is indicated. The purpose of this study was to explore inhospital and 1-year outcomes of patients undergoing alternative access TAVR through the transapical (TA) or transaortic (TAo) techniques in the United States.
  
  
  METHODS
  Clinical records of 4,953 patients undergoing TA (n = 4,085) or TAo (n = 868) TAVR from 2011 to 2014 in The Society of Thoracic Surgeons (STS)/American College of Cardiology Transcatheter Valve Therapy Registry were linked to Centers for Medicare and Medicaid Services hospital claims. Inhospital and 1-year clinical outcomes were stratified by operative risk; and the risk-adjusted association between access route and mortality, stroke, and heart failure repeat hospitalization was explored.
  
  
  RESULTS
  Mean age for all patients was 82.8 ± 6.8 years. The median STS predicted risk of mortality was significantly higher among patients undergoing TAo (8.8 versus 7.4, p < 0.001). When compared with TA, TAo was associated with an increased risk of unadjusted 30-day mortality (10.3% versus 8.8%) and 1-year mortality (30.3% versus 25.6%, p = 0.006). There were no significant differences between TAo and TA for inhospital stroke rate (2.2%), major vascular complications (0.3%), and 1-year heart failure rehospitalizations (15.7%). Examination of high-risk and inoperable subgroups showed that 1-year mortality was significantly higher for TAo patients classified as inoperable (p = 0.012).
  
  
  CONCLUSIONS
  Patients undergoing TAo TAVR are older, more likely female, and have significantly higher STS predicted risk of mortality scores than patients operated on by TA access. There were no risk-adjusted differences between TA and TAo access in mortality, stroke, or readmission rates as long as 1 year after TAVR.
authors.affiliation: Emory University, Atlanta, Georgia. Electronic address: vthoura@emory.edu.
authors.forename: Vinod H
authors.initials: VH
authors.lastname: Thourani
authors.affiliation: Emory University, Atlanta, Georgia.
authors.forename: Hanna A
authors.initials: HA
authors.lastname: Jensen
authors.affiliation: Emory University, Atlanta, Georgia.
authors.forename: Vasilis
authors.initials: V
authors.lastname: Babaliaros
authors.affiliation: Mayo Clinic, Rochester, Minnesota.
authors.forename: Rakesh
authors.initials: R
authors.lastname: Suri
authors.affiliation: Duke University School of Medicine and Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: Sreekanth
authors.initials: S
authors.lastname: Vemulapalli
authors.affiliation: Duke University School of Medicine and Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: David
authors.initials: D
authors.lastname: Dai
authors.affiliation: Duke University School of Medicine and Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: J Matthew
authors.initials: JM
authors.lastname: Brennan
authors.affiliation: University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, and Denver VA Medical Center, Denver, Colorado.
authors.forename: John
authors.initials: J
authors.lastname: Rumsfeld
authors.affiliation: University of Florida, Jacksonville, Florida.
authors.forename: Fred
authors.initials: F
authors.lastname: Edwards
authors.affiliation: Cleveland Clinic, Cleveland, Ohio.
authors.forename: E Murat
authors.initials: EM
authors.lastname: Tuzcu
authors.affiliation: Cleveland Clinic, Cleveland, Ohio.
authors.forename: Lars
authors.initials: L
authors.lastname: Svensson
authors.affiliation: University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Wilson Y
authors.initials: WY
authors.lastname: Szeto
authors.affiliation: University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Howard
authors.initials: H
authors.lastname: Herrmann
authors.affiliation: Columbia University, New York, New York.
authors.forename: Ajay J
authors.initials: AJ
authors.lastname: Kirtane
authors.affiliation: Columbia University, New York, New York.
authors.forename: Susheel
authors.initials: S
authors.lastname: Kodali
authors.affiliation: Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri.
authors.forename: David J
authors.initials: DJ
authors.lastname: Cohen
authors.affiliation: Emory University, Atlanta, Georgia.
authors.forename: Stamatios
authors.initials: S
authors.lastname: Lerakis
authors.affiliation: Emory University, Atlanta, Georgia.
authors.forename: Chandan
authors.initials: C
authors.lastname: Devireddy
authors.affiliation: Emory University, Atlanta, Georgia.
authors.forename: Eric
authors.initials: E
authors.lastname: Sarin
authors.affiliation: University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, and Denver VA Medical Center, Denver, Colorado.
authors.forename: John
authors.initials: J
authors.lastname: Carroll
authors.affiliation: Mayo Clinic, Rochester, Minnesota.
authors.forename: David
authors.initials: D
authors.lastname: Holmes
authors.affiliation: University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, and Denver VA Medical Center, Denver, Colorado.
authors.forename: Frederick L
authors.initials: FL
authors.lastname: Grover
authors.affiliation: New York University Langone Medical Center, New York, New York.
authors.forename: Mathew
authors.initials: M
authors.lastname: Williams
authors.affiliation: Washington University, St. Louis, Missouri.
authors.forename: Hersh
authors.initials: H
authors.lastname: Maniar
authors.affiliation: Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
authors.forename: David
authors.initials: D
authors.lastname: Shahian
authors.affiliation: Heart Hospital, Plano, Texas.
authors.forename: Michael
authors.initials: M
authors.lastname: Mack
mesh_terms: D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000401:mortality / Q000601:surgery*; D006328:Cardiac Catheterization / Q000379:methods* / Q000706:statistics & numerical data; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends; D065467:Transcatheter Aortic Valve Replacement / Q000706:statistics & numerical data*; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology