Does Addition of Transcarotid Approach to Transcatheter Aortic Valve Replacement Program Improve Outcomes for Nontransfemoral Cases

Purpose: Does addition of a transcarotid (Tc) approach to transcatheter aortic valve replacement (TAVR) program improve outcomes for nontransfemoral cases.

Materials and Methods: A retrospective analysis of consecutive nontransfemoral TAVR procedures performed at a single tertiary care medical center between 2016 and 2020 using the following alternate access: Tc, subclavian(Ts), or either transaortic or transapical (TAo or TAp). All outcomes are reported in accordance with the Valve Academic Research Consortium definitions.

Results: In the study period, a total of 131 patients were included: 77 patients received Tc, 45 Ts, and 9 TAo or TAp. Of the 131, 130(99.2%) received general anesthesia. STS risk score was comparable, 14.0 ± 7.2, 12.7 ± 10.0, 15.9 ± 8.8, P = 0.56. Operating room (OR) time (hours) trended shorter in Tc case, 2.1 ± 1.3, 2.4 ± 0.9, 3.1 ± 1.4, P = 0.053, and there were significant differences in Fluor dose (mGy) 613 ± 678, 1766 ± 1974, 956 ± 982, P < 0.001 and Fluoro time (min) 20.9 ± 8.3, 28.3 ± 7.2, 20.8 ± 8.3, P < 0.001 for Tc, Ts, and TAo or TAp, respectively. There were no differences in bleeding events (Tc, 6.5%; Ts, 4.4%, TAo or TAp, 11.1%; P = 0.73), stroke events (Tc, 5.2%; Ts, 8.9%; TAo or TAp, 22.2%; P = 0.18), stroke within 30 days (Tc, 5.2%; Ts, 6.7%; TAo or TAp, 22.2%; P = 0.16), vascular complications (Tc, 7.8%; Ts, 6.7%; TAo or TAp, 0.0%; P = 0.68), discharged home (as opposed to rehab) (Tc, 68.5%; Ts 69.0%; TAo or TAp, 33.3%; P = 0.10), or Afibrillation events (Tc; 0.0%; Ts, 4.4%; TAo or TAp, 11.1%; P = 0.06). There were no differences in 30-day mortality (Tc, 0.0%; Ts, 4.4%; TAo or TAp, 0.0%; P = 0.14); however, transcarotid TAVR was associated with a significant decrease in overall all-cause mortality(Tc, 0.0%, Ts, 8.9%, TAo or TAp, 0.0%; P = 0.02). Transcarotid TAVR was associated with a significant decrease in intensive care unit (ICU) stay (Tc, 42.9%; Ts, 66.7%; TAo or TAp, 100%; P = 0.001), and ICU length of stay (hours) (Tc, 20.4 ± 31.7; Ts, 50.1 ± 90.9, TAo or TAp, 33.5 ± 60.8; P = 0.033). In addition, transcarotid TAVR was associated with a significant decrease in hospital length of stay (Ts, 5.5 ± 31.7 days; 8.2 ± 8.1; TAo or TAp, 10.9 ± 9.3; P = 0.019).

Conclusions: Transcarotid approach to TAVR is safe and efficacious and improves outcomes for cases when the transfemoral approach is not feasible. This needs to be further validated with randomized controlled trials.