Long-Term Survival and Outcomes According to VARC-2 Criteria for Subclavian, Direct Aortic, Femoral, and Apical Implantation: An 8-Year United Kingdom TAVI Surgical Experience

Objectives: The use of transcatheter aortic valve implantation (TAVI) has expanded as an alternative to aortic valve replacement, and more than 500,000 patients have been treated worldwide since April, 2002. The aim of this study was to compare complications and morbidity/mortality associated with different TAVI approaches as alternatives to a surgical-femoral approach.

Methods: From January 2007 to January 2015, 2,863 patients underwent TAVI surgery in 36 United Kingdom TAVI centers. Primary outcomes were complications according to VARC-2 criteria. The secondary outcome was long-term survival.

Results: The enrolled patients were distributed as follows: 1,150 in the surgical-femoral (SF) group, 1,216 in the trans-apical (TA) group, 207 in the direct-aortic (DA) group, and 290 in the subclavian (SC) group. There were no differences in the rates of acute myocardial infarction, emergency valve-in-valve, cardiac tamponade, or TIA among the groups. The rates of stroke and renal replacement therapy, as well as in-hospital stay, in-hospital death, and 30-day and 12-month mortality in DA and TA were higher than those in SC and SF. The rates of paravalvular leak and balloon post-dilatation in SC and DA were higher than those in TA and SF. The rates of vascular injuries and permanent pacemaker implantation in SC and SF were higher than those in DA and TA. SF provided the best long term-survival (p = 0.008).

Conclusions: This was a large study that compared outcomes and long-term survival among different TAVI surgical approaches in a national real-world setting. According to our results, SF provided the best survival. While SC provided worse survival than SF, it was still better than TA and DA, and thus may represent the safest non-femoral access if use of the femoral approach is precluded.