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Transapical TAVR risky in patients with LV dysfunction
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Among patients with left ventricular dysfunction, transapical transcatheter aortic valve replacement conferred elevated risk for cardiac mortality compared with transfemoral TAVR, researchers reported.
Transapical TAVR was linked to increased all-cause mortality risk vs. transfemoral TAVR in patients regardless of LV function.
The researchers analyzed 2,084 patients from the PARTNER I trial to determine the impact of the transapical TAVR approach on mortality, LV ejection fraction improvement and functional recovery in those with LV dysfunction.
Patients were stratified by whether they had LV dysfunction, defined as LVEF less than 50%, at baseline, and the analysis was adjusted for the propensity of receiving transapical TAVR.
More than half (n = 1,057) of patients in the cohort underwent transapical TAVR.
Compared with transfemoral TAVR, TAVR with transapical access was associated with elevated risk for all-cause mortality at 2 years, regardless if a patient had LV dysfunction (adjusted HR = 1.52; 95% CI, 1.12-2.07) or not (adjusted HR = 1.38; 95% CI, 1.1-1.74), Sammy Elmariah, MD, interventional cardiologist and structural heart disease specialist at Massachusetts General Hospital and director of interventional structural heart disease at the VA Boston Healthcare System, and colleagues wrote.
Transapical TAVR, compared with transfemoral TAVR, also conferred increased 2-year cardiac mortality risk in patients with LV dysfunction (aHR = 1.92; 95% CI, 1.21-3.05), but not in those without LV dysfunction (aHR = 1.29; 95% CI, 0.87-1.9), according to the researchers.
Among those with LV dysfunction, transfemoral TAVR was linked to better improvement in LVEF (difference = 4.04%; 95% CI, 2.39-5.69) and 6-minute walk distance (difference = 45.1 m; 95% CI, 18.4-71.9) at 30 days compared with transapical TAVR, the researchers wrote.
“Avoidance of the transapical approach in patients with LV dysfunction in need of TAVR in favor of other alternative approaches appears prudent,” Elmariah and colleagues wrote.
In a related editorial, Kentaro Hayashida, MD, PhD, from the department of cardiology at Keio University School of Medicine, Tokyo, and Masanori Yamamoto, MD, PhD, from the department of cardiology at Toyohashi Heart Center in Toyohashi, Japan, wrote that the data are consistent with those from the OCEAN-TAVI real-world registry.
The transapical approach “has a risk of bleeding, myocardial injury and pseudoaneurysm formation and the invasiveness of ventriculotomy and thoracotomy,” they wrote. “Sometimes, patients cannot tolerate the invasiveness of this [transapical] approach; therefore, optimal patient selection is of utmost importance to improve clinical outcomes after [transapical] TAVR.” – by Erik Swain
Disclosures: The PARTNER trial was funded by Edwards Lifesciences. Elmariah reports he receives institutional research support from Boehringer Ingelheim, Edwards Lifesciences and Siemens, and consultant fees from Medtronic. Please see the study for a list of the other authors’ relevant financial disclosures. Hayashida and Yamamoto report they serve as clinical proctors for Edwards Lifesciences. Yamamoto also reports he serves as a clinical proctor for Medtronic.
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