ATS June 2009: Al-Attar, Nawwar, et al.  Transcatheter Aortic Valve Implantation: Selection Strategy Is Crucial for Outcome.  Ann Thor Surg, 2009, 87: 1757-1763.

In a rather exciting report in the June Annals of Thoracic Surgery, Al-Attar et al (Paris) describe their experience with transcatheter aortic valve implantation in 50 patients (Edwards-SAPIEN, Edwards Lifesciences Inc, Irvine, CA).  All patients had aortic stenosis in the context of important risk factors for open surgical implantation.  Mean age was 83.6 years, and most patients were in NYHA class III and IV. The predicted surgical mortality was 28% (European System for Cardiac Operative Risk Evaluation). Transfemoral access for valve implant was the preferred option (35 cases), and if contraindicated, the transapical approach was used (15 cases). The transapical patients had more comorbidity (diabetes, previous myocardial infarction, previous coronary artery bypass grafting, peripheral artery disease, renal failure, porcelain aorta, and previous stroke).

Successful implantation occurred in 85.7% and 100% in the transfemoral and transapical group, respectively.  In-hospital mortality was 8% in the transfemoral and 27% in the transapical group. Overall 1-year survival was 74% 11% in the transfemoral group and 60% 13% in the transapical.  

The authors concluded that the results attributed to each approach (transfemoral or transapical) are strongly influenced by the selection strategy. Patients in the transapical group had more comorbidity and consequently a more critical early postoperative period. The respective places of

transfemoral and transapical approaches need to be clarified for each approach by a randomized study.