Background:In some patients, the alternative access route for transcatheter aortic valve replacement (TAVR) is utilized because the conventional transfemoral approach is not felt to be either feasible or optimal. However, accurate prognostication of patient risks is not well established. This study examines the associations between peripheral (transsubclavian/transaxillary, and transcarotid) versus central access (transapical and transaortic) in alternative access TAVR and 30-day and 1-year end points of mortality and stroke for all valve platforms.Methods:Using data from The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry with linkage to Medicare claims, patients who underwent alternative access TAVR from June 1, 2015 to June 30, 2018 were identified. Adjusted and unadjusted Cox proportional hazards modeling were performed to determine the association between alternate access TAVR site and 30-day and 1-year end points of mortality and stroke.Results:Of 7187 alternative access TAVR patients, 3725 (52%) had peripheral access and 3462 (48%) had central access. All-cause mortality was significantly lower in peripheral access versus central access group at in-hospital and 1 year (2.9% versus 6.3% and 20.3% versus 26.6%, respectively), but stroke rates were higher (5.0% versus 2.8% and 7.3% versus 5.5%, respectively; all P<0.001). These results persisted after 1-year adjustment (death adjusted hazard ratio, 0.72 [95% CI, 0.62–0.85] and stroke adjusted hazard ratio, 2.92 [95% CI, 2.21–3.85]). When broken down by individual subtypes, compared with transaxillary/subclavian access patients, transapical, and transaortic access patients had higher all-cause mortality but less stroke (P<0.05).Conclusions:In this real-world, contemporary, nationally representative benchmarking study of alternate access TAVR sites, peripheral access was associated with favorable mortality and morbidity outcomes compared with central access, at the expense of higher stroke. These findings may allow for accurate prognostication of risk for patient counseling and decision-making for the heart team with regard to alternative access TAVR.

中文翻译：

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外周与中央通路替代通路经导管主动脉瓣置换术与死亡率和中风之间的关联：来自胸外科医师协会/美国心脏病学会经导管瓣膜治疗登记处的报告

背景：在一些患者中，使用了经导管主动脉瓣置换术 (TAVR) 的替代通路，因为认为传统的经股动脉方法既不可行也不最佳。然而，对患者风险的准确预测尚未得到很好的建立。本研究探讨了替代通路 TAVR 中外周通路（经锁骨下/经腋窝和经颈动脉）与中央通路（经心尖和经主动脉）以及所有瓣膜平台的 30 天和 1 年死亡率和卒中终点之间的关联。方法：使用数据从胸外科医师协会/美国心脏病学会经导管瓣膜治疗登记处与医疗保险索赔相关联，确定了 2015 年 6 月 1 日至 2018 年 6 月 30 日期间接受替代通路 TAVR 的患者。进行了调整和未调整的 Cox 比例风险模型以确定替代通路 TAVR 部位与 30 天和 1 年死亡率和卒中终点之间的关联。结果：在 7187 例替代通路 TAVR 患者中，3725 名（52%）有外周通路和 3462 (48%) 具有中央访问权限。在院内和 1 年，外周通路组的全因死亡率显着低于中心通路组（分别为 2.9% 对 6.3% 和 20.3% 对 26.6%），但卒中发生率更高（5.0% 对 2.8% 和 7.3%） % 与 5.5%，分别；所有P <0.001)。这些结果在 1 年调整后仍然存在（死亡调整风险比，0.72 [95% CI，0.62–0.85] 和卒中调整风险比，2.92 [95% CI，2.21–3.85]）。按个体亚型细分时，与经腋/锁骨下通路患者相比，经心尖和经主动脉通路患者的全因死亡率较高，但卒中较少（P <0.05）。结论：在这项现实世界、当代、具有全国代表性的基准研究中在备用通路 TAVR 部位中，与中心通路相比，外周通路与有利的死亡率和发病率结果相关，但以更高的卒中为代价。这些发现可以准确预测患者咨询和心脏团队关于替代通路 TAVR 决策的风险。