Author + information
- Published online February 13, 2019.
- aDepartment of Cardiovascular Surgery, Houston Methodist Hospital, Houston, Texas
- bDepartment of Cardiology, Houston Methodist Hospital, Houston, Texas
- ↵∗Address for correspondence:
Dr. Michael J. Reardon, Houston Methodist Hospital, Cardiothoracic Surgery, 6550 Fannin, Suite 1401, Houston, Texas 77030.
The early days of transcatheter aortic valve replacement (TAVR) saw the valves delivered in a “cardiology” fashion as transfemoral (TF) or in a “surgical” fashion as transapical (TA) for balloon-expandable valves or direct aortic (DA)/trans-subclavian for the self-expanding valve. The non-TF access methods were labeled as “alternative access.” It is not surprising to any of us that the field developed improved equipment and techniques allowing for the continued expansion of the role of TF TAVR. It may well be time to consider what TAVR access should be considered “standard” and which “alternative,” and where the split between “surgical” and “nonsurgical” begins.
The first author of a paper in this issue of JACC: Cardiovascular Interventions, Thomas Modine (1), has been a leader in both the overall field of TAVR as well as a pioneer in developing the transcarotid access technique. The current article by Modine et al. (1) expands on this and looks at the French Transcarotid Registry from 2014 to 2018 for cases of transcarotid TAVR using the current-generation Sapien 3 balloon-expandable valve (Edwards Lifesciences, Irvine, California). From the 13 participating centers, there were 6,680 patients during the study period. This included 314 (4.7%) who had transcarotid access with a mean age of 83 years and mean STS score of 5.8%. Almost three-fourths were done using a left carotid access with a 97% procedural success rate. The vast majority was done under general anesthesia although local anesthesia with sedation was possible. The 30-day mortality was a very respectable 3.2% in this group deemed to be at high or extreme risk. All patients were deemed anatomically unsuitable for TF access. All patients had careful evaluation of the circle of Willis as well as documentation of the absence of severe stenosis or occlusion of the contralateral carotid or vertebral arteries. All patients suspected of any neurological event were seen by a senior neurologist and underwent diagnostic neuroimaging whenever indicated according to the neurologist. The major concern TAVR implanters have with transcarotid access is the potential for stroke related to the procedure. In this study, there was a surprisingly low neurological event rate with 5 events (1.6%) of which 3 were strokes in the first 24 h. Of these strokes, 2 were contralateral and 1 ipsilateral to the access side. There was only 1 major bleeding event related to the access, and that was treated with transfusion. Dr. Modine and his collaborators have shown that transcarotid TAVR can be done with excellent safety and efficacy, and with outcomes that appear to us to be similar to TF access in an equivalent group of patients. We agree with their conclusion that a transcarotid access with the Sapien 3 is safe and effective. Whether this is your first choice if TF is not available will be for each TAVR team to decide. We do believe, however, that the concept of “alternative access” needs to be reconsidered in light of the pioneering work of Dr. Modine and others.
We remember (M.J.R.) debating at various meetings in the early days of TAVR whether DA or TA access was the preferred alternative access. (For transparency, M.J.R. debated the pro-DA side). In those debates, it was not uncommon to have surgeons claim that TA-access TAVR was just as good as TF-access TAVR, and that without randomized trials, we would never know. The authors believe that any TAVR access that puts an opening through your chest wall (much less through your left ventricle) will never be as acceptable to patients or have the recovery aspects of an access that does not penetrate the chest wall unless that access itself creates new morbidity for the patient (such as a significant increase in stroke). A randomized trial between DA or TA TAVR and TF TAVR will never likely be done, and we would not support one. Trans-subclavian (or transaxillary for anatomic purists) has already been shown to be equivalent to TFG access TAVR (2). The group led by Dr. Modine has gone a long way to showing us that transcarotid access does not have the feared neurological consequences and may well also be equivalent to subclavian and TF access. In addition, the exposure of the carotid artery is even technically simpler than exposing the axillary artery with its close relationship to the brachial plexus. Either is easy for an experienced cardiovascular surgeon to expose. Will structural heart–oriented interventional cardiologists eventually strive to gain the training and experience to do these “alternative access” procedures? If so, transcarotid will be easier to teach and perform due to the easily accessible anatomic location of the carotid arteries. We have used transcarotid access with the Evolut valve (Medtronic, Minneapolis, Minnesota) and found a similar ease of use and safety. Our approach differs in minor ways. We do not use a counter incision for the sheath to provide stability. We do strongly agree that the operator needs to insure sheath stability so that during the TAVR, one can focus on valve deployment and not sheath stability. Heart surgeons, of course, place a cannula into the ascending aorta for bypass on a daily basis and secure this with sutures and not a counter incision. Stability and not how you achieve this is the key. We also access the ipsilateral internal jugular vein from a separate skin puncture for placement of the temporary pacer lead. This is technically simple with the internal jugular vein juxtaposed to the internal carotid artery that is exposed. If the need for pacing after the procedure arises this allows a trans jugular temporary pacer that is comfortable for the patient and stable in the post procedure period without having to move from a femoral location. We believe that TF access should be considered the “standard” and that any other routes that can show safety, efficacy, and recovery similar to TF access should also be considered standard and not alternative access. Other non-chest wall–penetrating access may also eventually achieve results similar to TF once enough experience and data are acquired, and that access will eventually be divided into transthoracic and nontransthoracic. The choice of nontransthoracic routes will likely depend only on the experience and choice of the local heart teams.
We congratulate Modine et al. (1) on their excellent outcomes and thank them for pioneering this useful approach to TAVR access.
↵∗ Editorials published in JACC: Cardiovascular Interventions reflect the views of the authors and do not necessarily represent the views of JACC: Cardiovascular Interventions or the American College of Cardiology.
Dr. Reardon has served on an advisory board for Medtronic. Dr. Barker has reported that he has no relationships relevant to the contents of this paper to disclose.
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