TRIP

Direct Aortic Access for TAVI Shows Promise (CME/CE)

MedPageToday, 2012

For comparison, in the (high-risk patients randomized to TAVI [n=348] or surgery [n=351]), the 30-day major stroke rate for TAVI was 3.8%, for mortality 3.4%, and for major bleeding 9.3%.
Bapat noted that the initial protocol at his facility was to attempt the transfemoral approach first and if that was not possible, try transapical and then transaortic.
But now, if a patient is not suitable for the transfemoral approach, they immediately go for transaortic access.
But several attendees wanted to know why the transaortic approach was not the first choice, given its excellent outcomes.
Bapat said it might be difficult to "sell" the transaortic approach to patients because it involves a 5-cm incision in the chest, either via a mini-sternotomy or a mini-thoracotomy, as opposed to a short incision at the groin.
It also was noted that no data exist from randomized clinical trials showing that one approach is better than the other, so transfemoral access need not be the default approach.
In the study headed by Bapat, researchers retrospectively examined data from 158 patients (out of a total of 1,236 in the European Multicenter Experience) who underwent TAVI with the Sapien valve using the transaortic approach.
Nearly 40% had peripheral vascular disease, one-quarter had diabetes, 13% had previous coronary artery bypass grafting (CABG), 37% had chronic obstructive pulmonary disease, 35% had an ejection fraction less than 50%, and the mean Euroscore was 32 -- indicating a significant preoperative risk of mortality with standard surgery.
All cases had only one valve deployed and all cases underwent preplanning using CT scans, which both Bapat and Moat said is essential in all TAVI cases.
In particular, CT scans can help with the following: Determine if the aortic access site is ≥6 cm from the annulus Assess location of the ascending aorta Select access site to achieve a delivery trajectory that optimizes coaxial alignment with native aortic valve Assess calcification Identify critical vessels, especially location and course of patent LIMA or RIMA (left or right internal mammary artery) grafts
In the study headed by Moat, researchers retrospectively examined data from 93 patients having the CoreValve implanted directly through the aorta.