Transcarotid versus transthoracic access for transcatheter aortic valve replacement: A propensity-matched analysis

Reply: Time to embrace transcarotid transcatheter aortic valve replacement—new route, same valve

“…Although we do not have direct insight to the degree of internal carotid stenosis, level of expertise of the TAVR teams with carotid access, preprocedure evaluation, technical details, or specific factors involved in the decision to perform TC TAVR from the TVT report, 2 it is evident that this report reflects the initial experience and learning curve with these procedures. As with all surgical procedures, experience and a systematic and reproducible approach are critical for improving outcomes.…”

“…In his commentary, Dr Usenini 1 highlights some of the variables of interest missing from the TC Transcatheter Valve Therapy (TVT) report, 2 including rates of paravalvular leak, degree of internal carotid stenosis, stroke risk, and questions the appropriateness of TC TAVR. Although there are many factors impacting paravalvular leak (device type and generation, appropriate sizing, distribution of annular calcification, etc), 3 access site is unlikely to significantly impact the rate or degree of paravalvular leak.…”

Patient-Tailored Aortic Valve Replacement

“…Although transapical access was the most used alternative access in the early days of TAVR, there is now a worldwide tendency to avoid transthoracic access and use percutaneous transvascular alternative access instead. Over the past few years, transaxillary, transsubclavian and transcarotid access have become the more popular alternative access routes for TAVR (30)(31)(32). Transapical TAVR may also still be needed, thereby requiring "reverse" loading of the THV within its delivery system.…”

Reply from authors: Transcarotid trumps transapical/direct aortic access for transcatheter aortic valve replacement—It's a no brainer!

“…We appreciate the interest that Dr Useini 1 showed in our recent article, "Transcarotid versus transthoracic access for transcatheter aortic valve replacement: a propensitymatched analysis." 2 Although we agree that the need for nonfemoral access is declining, Useini's insistence on clinging to an intrathoracic (transapical/direct aortic) access when femoral access is inadequate is misguided. In a propensity-matched analysis using the Society of Thoracic Surgeons and American College of Cardiology Transcatheter Valve Therapy (TVT) Registry, compared with transapical/direct aortic access using the SAPIEN 3 heart valve, transcarotid access was associated with lower in-hospital mortality (2.4% vs 5.7%; P ¼ .0009) and 30-day mortality (4.2% vs 7.7%; P ¼ .004), less new-onset atrial fibrillation (2.2% vs 12.1%; P <.0001), shorter median hospital length of stay (LOS) (3 days vs 6 days; P < .0001), shorter median intensive care unit (ICU) LOS (25.0 hours vs 47.2 hours; P < .0001), more frequent discharge to home (81.6% vs 59.1%; P < .0001), fewer readmissions at 30 days (9.8% vs 16.1%; P ¼ .0006), and a greater improvement from baseline to 30 days in the Kansas City Cardiomyopathy Questionnaire score (25.1 vs 20.8; P ¼ .007).…”