Transcatheter Aortic Valve Implantation: Selection Strategy Is Crucial for Outcome

Background. We describe the results of transcatheter aortic valve implantation (TAVI) in high-risk patients with aortic stenosis. Transfemoral access was the first option, and if contraindicated, the transapical approach was used. Methods. Fifty patients were consecutively treated with TAVI because of high surgical risk or contraindications to operation. Mean age was 83 +/- 6 years, and most were in New York Heart Association classes III and IV. The predicted surgical mortality was 28% +/- 14% using the European System for Cardiac Operative Risk Evaluation and 16% +/- 7% using the Society of Thoracic Surgeons Predicted Risk of Mortality. The Edwards-SAPIEN (Edwards Lifesciences Inc, Irvine, CA) valve was implanted using a transfemoral approach in 35 patients and the transapical approach in 15. The transapical patients had more comorbidity (diabetes, previous myocardial infarction, previous coronary artery bypass grafting, peripheral artery disease, renal failure, porcelain aorta, and previous stroke). Results. Successful implantation was 85.7% and 100% in the transfemoral and transapical group, respectively. Gradients were satisfactory. In-hospital mortality was 8% in the transfemoral and 27% in the transapical group. Stroke was only observed in the transfemoral group. Overall 1-year survival was 74% +/- 11% in the transfemoral group and 60% +/- 13% in the transapical. Conclusions. The results attributed to each approach (transfemoral or transapical) are strongly influenced by the selection strategy. Patients in the transapical group had more comorbidity and consequently a more critical early postoperative period. The respective places of transfemoral and transapical approaches need to be clarified for each approach by a randomized study. (Ann Thorac Surg 2009; 87: 1757-63) (C) 2009 by The Society of Thoracic Surgeons