Propensity-matched comparison of percutaneous and surgical cut-down approaches in transfemoral transcatheter aortic valve implantation using a balloon-expandable valve
Selected in EuroIntervention by S. Brugaletta
Kawashima H, Watanabe Y, Kozuma K, Nara Y, Hioki H, Kataoka A, Yamamoto M, Takagi K, Araki M, Tada N, Shirai S, Yamanaka F, Hayashida K
EuroIntervention. 2017 Mar 20;12(16):1954-1961
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What is known
Transcatheter aortic valve implantation (TAVI) has become an essential part of everyday practice in the treatment of patients with severe symptomatic aortic stenosis who are ineligible or otherwise considered to be at high risk of complications for conventional surgical aortic valve replacement. Whereas first-generation transfemoral TAVI devices required larger calibre sheaths with 22 or 24 Fr inner diameters, requiring the use of surgical cut-down and closure to ensure appropriate access and haemostasis, with the decrease in sheath diameter percutaneous approach for femoral access has increase. However, little is known about the advantages and disadvantages of this percutaneous approach. The aim of this study was to compare the percutaneous and surgical cut-down approaches with regard to the clinical outcomes of patients undergoing transfemoral TAVI.
- Between October 2013 and July 2015, 586 patients underwent transfemoral TAVI according to the Optimized CathEter vAlvular iNtervention (OCEAN)-TAVI registry (percutaneous approach, n=305; surgical cut-down approach, n=281)
- After propensity matching, 166 patients underwent transfemoral TAVI via each approach
- Major vascular complications, as defined per the Valve Academic Research Consortium-2 criteria, were found less frequently in patients who underwent a percutaneous approach (15.1% vs. 27.1%, p<0.01), and femoral artery injuries requiring surgical repair were mostly the result of a closure device failure (seven cases, 4.2%).
- In these patients, major bleeding was less (7.2% vs. 16.9%, p=0.01) and blood transfusion less frequent (21.1% vs. 38.0%, p<0.01); therefore, cases of acute kidney injury (AKI) were rare (6.0% vs. 15.1%, p<0.01)
In the TAVI era, the minimally invasive approach is progressively increasing, thanks also to the improvements in TAVI technology and to the use of smaller femoral sheath for femoral approach. For these reasons, the percutaneous approach is increasing in TAVI practice. However, no randomized data are present to support safety and efficacy of this approach as compared to surgical approach. Data previously published coming from registries are contrasting. By using a propensity score matching analysis, the present paper showed better outcome of percutaneous approach as compared to surgical arm. There is still to define if there is a learning curve effect on this outcome and if there are criteria on how to select best patients for this approach.
Which kind of approach do you use in your TAVI practice?