Propensity-Matched Comparisons of Clinical Outcomes after Transapical or Transfemoral TAVR: A PARTNER-I Trial Substudy
Background—Higher risk of adverse outcomes after transapical (TA) vs. transfemoral (TF) transcatheter aortic valve replacement (TAVR) could be due to TA-TAVR being an open surgical procedure or to clinical differences between TA- and TF-TAVR patients. We compared outcomes after neutralizing patient differences using propensity-score matching.
Methods and Results—From 4/2007-2/2012, 1100 PARTNER-I patients underwent TA-TAVR and 1521 TF-TAVR using Edwards SAPIEN balloon-expandable bioprostheses. Propensity matching based on 111 pre-procedural variables, exclusive of femoral access morphology, identified 501 well-matched patient pairs (46% of possible matches), 95% of whom had peripheral arterial disease. Matched TA-TAVR patients experienced more adverse procedural events, longer length of stay (5 vs. 8 days, p<0.0001), and slower recovery (New York Heart Association class I 31% vs. 38% at 30 days, equalizing by 6 months at 51% vs. 47%); stroke risk was similar (3.4% vs. 3.3% at 30 days and 6.0% vs. 6.7% at 3 years); mortality was elevated for the first 6 post-procedure months (19% vs. 12%, p=0.01), but aortic regurgitation was less (34% vs. 52% mild and 8.9% vs. 12% moderate-severe at discharge, p=0.001; 36% vs. 50% mild and 10% vs. 15% moderate-severe at 6 months, p<0.0001).
Conclusions—Likelihood of adverse periprocedural events and prolonged recovery is greater after TA-TAVR than TF-TAVR in vasculopathic patients after accounting for differences in cardiovascular risk factors, although stroke risk is equivalent and aortic regurgitation less. As smaller delivery systems permit TF-TAVR in many of these patients, we recommend a TF-first access strategy for TAVR when anatomically feasible.
Clinical Trial Registration—www.clinicaltrials.gov. Identifier: NCT00530894.
- paravalvular regurgitation
- aortic valve regurgitation
- aortic valve replacement
- propensity score
- Received July 28, 2014.
- Revision received February 16, 2015.
- Accepted March 19, 2015.