Barcelona, Spain – Sunday 31 August 2014: Transfemoral access reduces mortality, strokes and bleeding in transcatheter aortic valve implantation (TAVI) compared to the transapical approach, according to a study of more than 10 000 patients presented at ESC Congress today by Dr Federico Conrotto from Città della Salute e della Scienza Hospital in Turin, Italy.
Dr Conrotto said:
“High risk patients with severe aortic stenosis may be treated with TAVI as an alternative to cardiac surgery. Two main access sites have been largely exploited, transfemoral and transapical. Transfemoral aortic valve implantation has the advantage of being a completely percutaneous procedure while transapical aortic valve implantation is a more invasive procedure, needing direct puncture of the left ventricle.”
“Until now, there have been a lack of randomised studies investigating the different TAVI approaches and a comparison between the effects of the transfemoral and transapical strategies on TAVI clinical outcomes remains challenging. Registry data have suggested that transapical access could be associated with a worse prognosis but the bias of a higher baseline risk in the patients studied may have inﬂuenced these results.”
To clarify the impact of a transfemoral versus transapical approach on short and mid-term TAVI outcomes, the researchers performed a meta-analysis of observational studies that reported the independent impact of the choice of access site on TAVI outcome.
The researchers conducted a systematic review of contemporary literature. Their meta-analysis included 13 studies and 10 468 patients treated for symptomatic severe aortic stenosis between 2005 and 2012. The median age of patients was 82 years and half of the patients were male. Transfemoral access was the preferred site in 69.5% of TAVI procedures while transapical access was used in 30.5% of cases.
The researchers found that 30 day survival was higher in transfemoral patients with a pooled adjusted odds ratio (OR) of 0.81 [0.68-0.97]. Regarding periprocedural outcomes, transfemoral access also significantly reduced the risk of bleeding and strokes (OR respectively of 0.74 [0.66-0.82] and 0.91 [0.83-0.99]).
Dr Conrotto said:
“We found that 30 day survival was higher in the transfemoral group than in transapical group and that the rate of periprocedural bleeding and strokes was signiﬁcantly lower in transfemoral patients. This means that transfemoral access not only leads to a longer life, but it is also safer.”
“The short-term advantages we observed with the transfemoral approach periprocedurally and at 30 days remained statistically signiﬁcant at mid-term follow-up (365 days) (OR 0.85 [0.80-0.90]. Clinicians can be confident that the short-term gains with the transfemoral approach are not a trade off for worse outcomes later on.”
Dr Conrotto concluded:
“Transfemoral access should be considered the preferred access site for TAVI and be used whenever possible, meaning whenever good vascular access is present. This choice may guarantee less mortality, less stroke and less bleeding in this frail and elderly population. Transapical access should be limited to patients with small or unapproachable femoral vessels.”