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Embolic Risk In TAVI: Really "Transfemoral First"?

Guido Dohmen, Shahram Lotfi, Jan Spillner, Rainer Hoffmann, Nikolaus Marx, Ruediger Autschbach.
University Hospital Aachen, RWTH, Aachen, Germany.


OBJECTIVE: According to the less invasive character, most patients scheduled for transcatheter aortic valve implantation (TAVI) are screened and treated on a “transfemoral first” basis, mostly irrespective of aortic atherosclerotic disease. We applied a CT-based aortic calcification score as an estimate of the embolic risk to scrutinize this approach.
METHODS: 210 patients were treated by transapical (TA) (n=116, SAPIEN) or transfemoral (TF) (n=94, CoreValve) TAVI by the same multidisciplinary team. Prerequisite for TF-AVI was good vascular access. TA-patients were either not suitable for TF-AVI or had individual reasons for selection. Only exclusion criteria for TA-AVI was overlarged aortic annulus. To account for embolic risk a calcification-score was generated (ascending aorta, aortic arch and proximal descending aorta separately, 0=none, 1=sporadic, 2=multiple, 3=circular calcification).
RESULTS: Mean age was 79+7 (TA) and 81+6 (TF), mean EuroScore 31+ 16 (TA) and 15+ 9 (TF). There were 33 redo-cases (26 TA, 7 TF) including 4 valve-in-valve procedures (all TA). Mean calcification score was 2.88 (TA), versus 2.11 (TF) (p<0.05). Pacemaker-implantation was necessary in 5.2% (TA) and 45.7% (TF), stroke rate was 0 (TA) and 3.2% (TF). 30 day mortality was 10.3% (TA) and 13.8% (TF) and mainly determined by comorbidities and age (TA and TF) and arrhythmia (TF).
CONCLUSIONS: Despite a higher risk profile according to the aortic calcification score, short term outcome was favourable in the transapical patient group. This may argue against a “transfemoral first” policy. Further analysis may identify subgroups eligible for a particular approach.
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