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Meta-analysis confirms safety of transfemoral TAVR in older patients
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BARCELONA, Spain — Patients undergoing transfemoral transcatheter aortic valve replacement via the transfemoral route experienced improved mortality and bleeding outcomes compared with those undergoing transapical procedures, according to data presented here.
Federico Conrotto, MD, of the department of cardiology at Citta Della Salute e Della Science Hospital in Turin, Italy, suggested during a presentation that high-risk patients with severe aortic stenosis may be treated with TAVR as an alternative to cardiac surgery.
The current meta-analysis included 10,468 patients aged 82 years. Around one-quarter of patients had diabetes, while 17.8% had renal dysfunction, 61% had CAD and the average ejection fraction was 52.4%.
Conrotto noted that transapical TAVR is preferable in patients with small or unapproachable vessels, but that the transfemoral approach is useful when good vascular access is present.
Results indicated that logistic EuroSCORE was >20% in every study except one, in which the score was 18.5%. This score was also higher in patients undergoing transapical procedures than in those undergoing transfemoral procedures.
The pooled adjusted OR for mortality at 30 days was 0.81 (95% CI, 0.68-0.97). The pooled adjusted OR for midterm mortality was 0.85 (95% CI, 0.80-0.90).
“Transfemoral access seems to be protective in terms of mortality reduction in early and midterm periods,” Conrotto said. “Pooled adjusted 30-day mortality was lower in transfemoral access.”
The OR for periprocedural bleeding was 0.74 (95% CI, 0.66-0.82), while the OR for periprocedural stroke was 0.91 (95% CI, 0.83-0.99).
“Moreover, we found that transfemoral access leads not only to a longer life, but it is probably safer,” Conrotto said.
He concluded that the short-term advantage of the transfemoral approach remains statistically significant at midterm follow‐up. “Although the results of the present meta‐analysis should be viewed as hypothesis generating only, they suggest that [transapical] access should be reserved as a last option in TAVR patients,” he said. “This choice may guarantee less mortality, less stroke and less bleeding in this frail and elderly population.” – by Rob Volansky
For more information:
Conrotto F. Too Young to Die. Presented at: the European Society of Cardiology Congress; Aug. 30-Sept. 3, 2014; Barcelona, Spain.
Disclosure: Conrotto reports no relevant financial disclosures.
Perspective
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Kim Allan Williams, MD
This study is consistent with our observations on several fronts. We try the transfemoral approach in as many patients as possible. The delivery systems are getting smaller to allow more transfemoral procedures. The transfemoral approach should be less difficult and less painful than a minithoracotomy. However, patients who need the transapical approach typically have iliac vessels that are small or heavily calcified. They likely represent a different patient group, with more vascular disease, than those who are able to have the procedure done transfemorally. Thus, the poorer long-term outcome may have more to do with baseline differences, rather than the procedure itself. This is hypothesis generating, however, and doing a randomized study comparing the two in patients who are eligible for transfemoral would be needed to get to this conclusion. We have to be careful not to conclude that the procedure is better, when it may be that the patients are better.
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