Department of Cardiovascular Surgery, A. O. Santa Croce e Carle, Cuneo, Italy.
Department of Cardiovascular Surgery, Hopital Privé Jacques Cartier, Massy, France.
J Card Surg. 2021 Mar;36(3):872-878. doi: 10.1111/jocs.15313. Epub 2021 Jan 13.
Transaortic (TAo) and transapical (TA) implantation can be used in transcatheter aortic valve implantation (TAVI) when the transfemoral (TF) approach is precluded. We compare the safety and efficacy of these alternative techniques.
From October 2007 to February 2016, TAo and TA patients' data were collected. Propensity score inverse probability of treatment weight (IPTW) method was employed to minimize the impact of no-randomization bias.
From our single-center non-TF-TAVI registry, 282 patients were included: 235 (83.3%) underwent TAo and 47 (16.7%) TA. Differences in baseline characteristics were statistically significant in age, sex, risk profile according to logistic-EuroSCORE, and previous cardiac surgery. No difference in hospital morbidity and mortality, but lower stroke-rate in TAo (1.27% vs. 8.5% p < .01) was observed. This was confirmed at logistic regression after IPTW adjustment (odds ratio [OR]: 0.16, 95% CI 0.03-0.71, p = .01), together with reduced risk of the paravalvular leak (PVL) (OR: 0.14, 95% confidence interval [CI]: 0.02-0.81, p = .02). Kaplan-Meier estimates did not demonstrate differences in long-term mortality among access routes (logrank test p = .13). At the IPTW-Cox regression model, long-term mortality was related to New York Heart Association III-IV (hazard ratio [HR]: 2.92, 95% CI: 1.15-7.40, p = .026), chronic renal failure (HR: 3.25; 95% CI: 1.02-10.32 p = .046), previous transient ischemic attack/stroke (HR: 2.29, 95% CI: 1.25-4.20 p = .007). Sapien-3 device resulted to be a protective factor, reducing long-term mortality (HR: 0.18, 95% CI 0.04- 0.90 p = .03).
TAo is safe and feasible in case of contraindication to femoral approach demonstrating comparable midterm outcomes to TA, thus representing a central access alternative, to increase the overall safety of high-risk TAVI procedures.
经股动脉（TF）入路禁忌时，可采用经主动脉（TAo）和经心尖（TA）植入方法进行经导管主动脉瓣植入（TAVI）。我们比较了这些替代技术的安全性和有效性。
从 2007 年 10 月至 2016 年 2 月，收集了 TAo 和 TA 患者的数据。采用倾向评分逆概率治疗权重（IPTW）方法最小化非随机分组偏差的影响。
从我们的单中心非 TF-TAVI 注册中心，纳入 282 例患者：235 例（83.3%）行 TAo，47 例（16.7%）行 TA。年龄、性别、根据 logistic-EuroSCORE 的风险特征以及既往心脏手术等基线特征差异有统计学意义。两组住院发病率和死亡率无差异，但 TAo 组的卒中发生率较低（1.27% vs. 8.5%，p<0.01）。这在 IPTW 调整后的逻辑回归中得到证实（比值比[OR]：0.16，95%置信区间[CI]：0.03-0.71，p=0.01），同时也降低了瓣周漏（PVL）的风险（OR：0.14，95%CI：0.02-0.81，p=0.02）。Kaplan-Meier 估计显示不同入路的长期死亡率无差异（对数秩检验 p=0.13）。在 IPTW-Cox 回归模型中，长期死亡率与纽约心脏协会 III-IV 级（危险比[HR]：2.92，95%CI：1.15-7.40，p=0.026）、慢性肾功能衰竭（HR：3.25；95%CI：1.02-10.32，p=0.046）、既往短暂性脑缺血发作/卒中（HR：2.29，95%CI：1.25-4.20，p=0.007）有关。Sapien-3 装置是一个保护因素，降低了长期死亡率（HR：0.18，95%CI 0.04-0.90，p=0.03）。
TAo 在 TF 入路禁忌时是安全可行的，其中期结果与 TA 相当，因此代表了一种中心入路的替代方法，可以提高高危 TAVI 手术的整体安全性。
