title: Focus on the surgical approach to transcatheter aortic valve implantation: Complications, outcome, and preoperative risk adjustment.
abstract: OBJECTIVE
  Perioperative complications in patients undergoing transcatheter aortic valve implantation remain a major issue affecting outcome. Because preoperative risk adjustment remains challenging and a valid scoring system is missing, we sought to determine the incidence of peri- and postprocedural complications of transapical (TA) or transaortic (TAO) access to define the influence of specific complications on early safety, 30-day mortality, and 1-year survival. Furthermore, we aimed to develop a risk-stratification model to allow an estimation of the perioperative risk and the 1-year survival rate, based on the individual preoperative condition of each patient.
  
  
  METHODS
  We performed an outcome analysis of 230 consecutive patients who underwent aortic valve implantation via transapical or transaortic access between 2008 and 2012, with regard to Valve Academic Research Consortium II criteria, including univariate and multivariable regression analysis, to develop a risk-stratification model.
  
  
  RESULTS
  Thirty-day mortality was 12.7%. Estimated 1-year survival was 0.69 (95% confidence interval [CI], 0.631-0.757), and 3-year survival was 0.554 (95% CI, 0.474-0.634). Univariate logistic regression analysis revealed a significant influence on 30-day mortality in case of life-threatening bleeding (16.1-fold), abdominal complications (8.5-fold), and acute kidney injury (3.2-fold). Pacemaker implantation (odds ratio, 1.55; 95% CI, 0.42-5.81; P = .512) was not a significant predictor. Concerning use of intraprocedural hemodynamic bridging therapy via cardiopulmonary bypass (CPB), Cox regression analysis revealed no significant survival difference after 1 year. A preoperative risk-stratification model for 1-year survival revealed that a logistic European System for Cardiac Operative Risk Evaluation score >20%, preoperative existing coronary artery disease, and prior myocardial infarction appeared to be significant predictors for diminished survival.
  
  
  CONCLUSIONS
  Concerning intraprocedural complications, CPB support for hemodynamic stabilization is a safe treatment option. Therefore, the heart team approach with CPB standby represents a life-saving option. Attention should also be drawn to specialized and individual postoperative care, because nonprocedure-specific complications clearly affect postoperative short- and long-term outcome. In addition, the risk-stratification model might facilitate preoperative decision making.
authors.affiliation: Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany. Electronic address: maximilian.scherner@uk-koeln.de.
authors.forename: Maximilian
authors.initials: M
authors.lastname: Scherner
authors.affiliation: Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany.
authors.forename: Navid
authors.initials: N
authors.lastname: Madershahian
authors.affiliation: Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany.
authors.forename: Svenja
authors.initials: S
authors.lastname: Ney
authors.affiliation: Institute of Medical Statistics, Informatics, and Epidemiology, University Hospital of Cologne, Cologne, Germany.
authors.forename: Kathrin
authors.initials: K
authors.lastname: Kuhr
authors.affiliation: Department of Cardiology, University Hospital of Cologne, Cologne, Germany.
authors.forename: Stephan
authors.initials: S
authors.lastname: Rosenkranz
authors.affiliation: Department of Cardiology, University Hospital of Cologne, Cologne, Germany.
authors.forename: Tanja K
authors.initials: TK
authors.lastname: Rudolph
authors.affiliation: Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany.
authors.forename: Elmar
authors.initials: E
authors.lastname: Kuhn
authors.affiliation: Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany.
authors.forename: Ingo
authors.initials: I
authors.lastname: Slottosch
authors.affiliation: Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany.
authors.forename: Antje
authors.initials: A
authors.lastname: Deppe
authors.affiliation: Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany.
authors.forename: Yeong-Hoon
authors.initials: YH
authors.lastname: Choi
authors.affiliation: Department of Cardiology, University Hospital of Cologne, Cologne, Germany.
authors.forename: Stephan
authors.initials: S
authors.lastname: Baldus
authors.affiliation: Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany.
authors.forename: Thorsten
authors.initials: T
authors.lastname: Wahlers
mesh_terms: D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology; D012189:Retrospective Studies; D020379:Risk Adjustment; D015996:Survival Rate; D013997:Time Factors; D065467:Transcatheter Aortic Valve Replacement / Q000009:adverse effects* / Q000379:methods*; D016896:Treatment Outcome
keywords: TA-AVI; Tao-AVI; complications; outcome; predictors