title: Comparative survival after transapical, direct aortic, and subclavian transcatheter aortic valve implantation (data from the UK TAVI registry).
abstract: Many patients have iliofemoral vessel anatomy unsuitable for conventional transfemoral (TF) transcatheter aortic valve implantation (TAVI). Safe and practical alternatives to the TF approach are, therefore, needed. This study compared outcomes of alternative nonfemoral routes, transapical (TA), direct aortic (DA), and subclavian (SC), with standard femoral access. In this retrospective study, data from 3,962 patients in the UK TAVI registry were analyzed. All patients who received TAVI through a femoral, subclavian, TA, or DA approach were eligible for inclusion. The primary outcome measure was survival up to 2 years. Median Logistic EuroSCORE was similar for SC, DA, and TA but significantly lower in the TF cohort (22.1% vs 20.3% vs 21.2% vs 17.0%, respectively, p <0.0001). Estimated 1-year survival rate was similar for TF (84.6 ± 0.7%) and SC (80.5 ± 3%, p = 0.27) but significantly worse for TA (74.7 ± 1.6%, p <0.001) and DA (75.2 ± 3.3%, p <0.001). A Cox proportional hazard model was used to analyze survival up to 2 years. Survival in the SC group was not significantly different from the TF group (hazard ratio [HR] 1.22, 95% confidence interval [CI] 0.88 to 1.70, p = 0.24). In contrast, survival in the TA (HR 1.74, 95% CI 1.43 to 2.11; p <0.001) and DA (HR 1.55, 95% CI 1.13 to 2.14; p <0.01) cohorts was significantly reduced compared with TF. In conclusion, TA and DA TAVI were associated with similar survival, both significantly worse than with the TF route. In contrast, subclavian access was not significantly different from TF and may represent the safest nonfemoral access route for TAVI.
authors.affiliation: Department of Cardiology, Leeds Teaching Hospitals, Leeds, United Kingdom.
authors.forename: Georg M
authors.initials: GM
authors.lastname: Fröhlich
authors.affiliation: Centre for Epidemiology and Biostatistics, University of Leeds, Leeds, United Kingdom.
authors.forename: Paul D
authors.initials: PD
authors.lastname: Baxter
authors.affiliation: Department of Cardiology, Leeds Teaching Hospitals, Leeds, United Kingdom.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Malkin
authors.affiliation: Department of Vascular Surgery, Leeds Teaching Hospitals, Leeds, United Kingdom.
authors.forename: D Julian A
authors.initials: DJ
authors.lastname: Scott
authors.affiliation: Department of Cardiac Surgery, Royal Brompton Hospital, London, United Kingdom.
authors.forename: Neil E
authors.initials: NE
authors.lastname: Moat
authors.affiliation: Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom.
authors.forename: David
authors.initials: D
authors.lastname: Hildick-Smith
authors.affiliation: National Institute for Cardiovascular Outcomes Research, University College London, London, United Kingdom.
authors.forename: David
authors.initials: D
authors.lastname: Cunningham
authors.affiliation: Department of Cardiology, King's College Hospital, London, United Kingdom.
authors.forename: Philip A
authors.initials: PA
authors.lastname: MacCarthy
authors.affiliation: Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom.
authors.forename: Uday
authors.initials: U
authors.lastname: Trivedi
authors.affiliation: Department of Cardiology, James Cook University Hospital, Middlesborough, United Kingdom.
authors.forename: Mark A
authors.initials: MA
authors.lastname: de Belder
authors.affiliation: Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom.
authors.forename: Peter F
authors.initials: PF
authors.lastname: Ludman
authors.affiliation: Department of Cardiology, Leeds Teaching Hospitals, Leeds, United Kingdom. Electronic address: daniel.blackman1@nhs.net.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Blackman
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000401:mortality / Q000601:surgery*; D006328:Cardiac Catheterization; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology*; D011446:Prospective Studies; D012042:Registries; D018570:Risk Assessment / Q000379:methods*; D015996:Survival Rate / Q000639:trends; D065467:Transcatheter Aortic Valve Replacement / Q000379:methods*; D016896:Treatment Outcome; D006113:United Kingdom / Q000453:epidemiology