Alternative access for balloon-expandable transcatheter aortic valve replacement: Comparison of the transaortic approach using right anterior thoracotomy to partial J-sternotomy

作者：Okuyama Kazuaki; Jilaihawi Hasan; Mirocha James; Nakamura Mamoo; Ramzy Danny; Makkar Raj; Cheng Wen^*

来源：The Journal of Thoracic and Cardiovascular Surgery, 2015, 149(3): 789-797.

DOI：10.1016/j.jtcvs.2014.10.062

Objectives: For transcatheter aortic valve replacement ( TAVR), transaortic ( TAo) and transapical ( TA) approaches are major alternatives in cases unsuitable for the transfemoral approach. Partial J- sternotomy is a widely used access for TAo. However, redo sternotomy or right- sided aorta may preclude this access, and right anterior thoracotomy is potentially beneficial in these cases. This study sought to evaluate the TAo approach using thoracotomy ( T- TAo) and compare it to the TAo approach using a sternotomy ( S- TAo) and a TA approach. Methods: In a large single- center series, consecutive TAVR patients were studied. Procedural/ clinical outcomes of the T- TAo, S- TAo, and TA groups were compared up to a 30 days follow- up period. Results: Of 872 TAVR patients, 22 ( 2.5%) were T- TAo, 29 ( 3.3%) were S- TAo, and 86 ( 9.9%) were TA approaches. The TA group showed the shortest intensive care unit stay, with a median 2.0 ( interquartile range 1.0- 3.0) days: for T- TAo it was 3.0 ( 2.0- 5.3) and for S- TAo, 3.0 ( 3.5- 5.0) ( P<. 001). Although it was not statistically significant, the T- TAo group showed numerically less mortality ( 1 [ 4.5%], 5 [ 17.9%], and 8 [ 9.4%] in the T- TAo, S- TAo, and TAgroups, respectively; P .30), with no difference in other endpoints, including stroke/ transient ischemic attack, rehospitalization, and paravalvular leak. Additionally, computed tomographic assessment revealed that T- TAo facilitated a more coaxial approach than S- TAo: 20.4 8.2 versus 30.6 8.2 ( P<. 001). Conclusions: T- TAo is a feasible approach that can provide greater coaxiality. This option allows tailored and optimal access to the individual patient and facilitates a treatment strategy in nontransfemoral TAVR patients.

• 出版日期2015-3