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When transfemoral transcatheter aortic valve replacement (TAVR) is not feasible, the next best access route may be the transaortic approach, a single-center study suggested.

With transfemoral TAVR, there were nonsignificant trends for lower 30-day mortality (5% versus 9% for transaortic TAVR, P=0.057) and a on Kaplan-Meier analysis (log-rank P=0.067), , of Hôpital Privé Jacques Cartier in France, and colleagues reported in the Nov. 28 issue of JACC: Cardiovascular Interventions.

While there was no difference in 30-day mortality between transaortic and transapical TAVR (9% versus 14%, P=0.283), there was what the researchers called a trend toward better 1-year survival on Kaplan-Meier analysis with transaortic TAVR over the transapical alternative, albeit with a nonsignificant log-rank P=0.154.

"The transaortic approach can be considered as an alternative to the transapical approach when the transfemoral approach seems unsuitable," Lefèvre's group concluded.

"Until recently, the transapical approach has been selected mainly as an alternative route when the transfemoral approach is not suitable. However, because of its feasibility and given the simplicity of the procedure, the transaortic approach has become increasingly used as a preferred approach among non-transfemoral patients."

The bottom line is that "the transaortic approach is feasible and safe," the authors suggested.

Lefèvre and colleagues took data from a prospective TAVR database of all consecutive high-risk patients with severe symptomatic aortic stenosis treated since October 2006 with TAVR via transfemoral (n=467) and transaortic (n=289) access. Because the hospital started doing transapical TAVR in 2010, the analysis included only the 42 cases done since January 2011 in order to exclude the learning period.

Balloon-expandable prostheses were used in 69% of transfemoral, 72% of transaortic, and all cases of transapical TAVR. Self-expanding valves were employed otherwise.

In an , , of Atlanta's Emory University Hospital, and , of the Heart Hospital Baylor Plano, Texas, cited several reasons why the transfemoral route has become the default for TAVR -- minimalist approaches, lower resource utilization, no need for a surgical incision -- yet they agreed with the investigators that there are populations that will need an alternative access site.

However, they pointed to the lack of statistical significance between the transaortic and transapical strategies in the present study and suggested instead "one might say it makes no difference which alternative route is chosen."

That a final verdict between the two remains to be reached is important news for surgeons contemplating transapical TAVR but who are concerned about performing a left ventriculotomy in patients with a low left ventricular ejection fraction or for operators who favor a small manubriotomy or right parasternal incision over an apical minithoracotomy for access, they wrote.

Moreover, "most experienced centers have developed their own comfort level with their favored alternative access approach with transaortic or subclavian access preferred when significant left ventricular dysfunction or severe chronic obstructive pulmonary disease is present."

Noting that the bulk of the literature on alternative TAVR approaches lies on small case series, there is a clear need for further study, Block and Mack emphasized.